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LECTURES, 



CLINICAL AND DIDACTIC, 



ON THE 



Diseases of Women 



BY 



R. LUDLAM, M.D., 



PROFESSOR OF OBSTETRICS AND THE DISEASES OF WOMEN AND CHILDREN IN THE HAHNEMANN 
MEDICAL COLLEGE, OF CHICAGO ; 

LATE PRESIDENT OF THE AMERICAN INSTITUTE OF HOMOEOPATHY ; 

PRESIDENT OF THE CHICAGO ACADEMY OF MEDICINE; GYNAECOLOGIST TO THE SCAMMON HOSPITAL; 

OBSTETRICAL EDITOR OF THE UNITED STATES MEDICAL AND SURGICAL JOURNAL ; 

AUTHOR OF A VOLUME OF CLINICAL LECTURES ON DIPHTHERIA ; ETC., ETC. 



SECOND EDITION. 



'* 



" Artists are few, 
" Teachers are thousands, and the world is large." 

Dr. Holland. 



CHICAGO: C. S. HALSEY. 
Philadelphia: F. E. Bgericke. London: Homoeopathic Pub. Co. 

1872. 




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Entered according to Act of Congress, in the year 1872, by 

C. S. HALSEY, 

in the Office of the Librarian of Congress, at Washington 




I. TISDALE TALBOT, M.D., 

OF BOSTON, 

PRESIDENT OF THE AMERICAN INSTITUTE OF HOMCEOPATHY AND 
EDITOR OF THE NEW ENGLAND MEDICAL GAZETTE, 



IN APPRECIATION OF HIS ABILITY AS A PHYSICIAN, HIS ATTAINMENTS AS A SCHOLAR, AND OF HIS 
HIGH PERSONAL CHARACTER ; — 



ALSO, 

To the Alumni and Students of the 

HAHNEMANN MEDICAL COLLEGE, 

OF CHICAGO. 

IN ACKNOWLEDGMENT OF THEIR KIND ATTENTION TO THESE LECTURES, AND OF THE MANY 

EXPRESSIONS OF THEIR REGARD WHICH HAVE STIMULATED AND ENCOURAGED 

THE PREPARATION OF THE WORK , 

THIS VOLUME IS RESPECTFULLY DEDICATED BY THEIR FRIEND AND FELLOW-LABORER, 



The Author. 



PREFACE 



The following lectures are the substance of those delivered by 
the author in the college and hospital in which he has served in 
the capacity of a teacher for many years. Most of them were 
condensed by careful hands in the lecture-room ; others were 
written at home ; all are based upon actual experience. The text 
illustrates a series of cases which were selected because they were 
typical, and not because they were anomalous. They, therefore, 
constitute what naturalists style a type-collection. Each of these 
cases is genuine, the report thereof being from notes which were 
taken upon the spot, and not trusted to the tabula rasa of profes- 
sional memory. The great majority of them were obtained from 
the College Dispensary and the Hospital ; others were derived 
from a large consulting field, and a few (to add to the variety 
and force of the illustration) from the author's private case-book. 

These cases have not been given in all their tedious detail, 
especially after the treatment was begun, but they have been 
analyzed and prescribed for in accordance with the author's best 
skill and judgment. Whenever it has seemed especially impor- 
tant, the result has been noted. They are not offered as models 
of excellent and accurate prescribing, which are complete in 
themselves and perfect of their kind , but are designed to be 
suggestive of the scope of practical medicine, surgery and hygiene, 
as applied to this specialty. 

Clinical lectures permit the practical recognition of many 
minor points that are likely to be passed over in more stately 
treatises ; and hence, if faithfully reported, approximate the more 



11 PREFACE. 

nearly to actual bed-side experience. The old maxim which 
holds that "History repeats itself" is true in Medicine. The 
clinical history of the various diseases to which attention has 
been called in these lectures will repeat itself in the experience 
of those who first heard them in the amphitheatre, and who may 
hereafter consult them in the printed form. That the lessons 
drawn may be suggestive, valuable and trustworthy in every par- 
ticular, has been the chief object in their preparation. 

The author herewith returns thanks to his professional breth- 
ren for their practical suggestions and the complimentary recep- 
tion and recognition of his services in years that are past. This 
relation has not only been most grateful to him, but it has also 
served greatly to extend the field of his observation and experi- 
ence in this specialty. 

The lectures were reported by Drs. A. W. "Woodward, H. T. 
F. Gatchell, E. Mussina, and the lamented W. Brendemuehl. 
The fidelity with which this work was done merits the thanks of 
the reader as well as of the author. And so likewise does the care- 
ful supervision of the press by his friend and colleague Prof. R. 
N. Foster. With these acknowledgments and without any apol- 
ogy for haste in its preparation, the work is herewith submitted to 
the profession. 

Chicago, October i, 1872. 



CONTENTS 



LECTURE I, 

Prolapsus Uteri with Dropsy, dating from the Climacteric, - - 17 

Parturition a cause of uterine deviation. The climacteric period predisposes 
thereto. Dropsy at the climacteric and constipation causes of prolapsus, 18. 
Postural treatment and therapeutical practice. Hygienic precautions and 
remedies, 19. 

Leucorrhcea with Chronic Ovaritis, - - - - . - 20 

Burning pain in ovaritis. Ovulation sometimes a constant cause. Reflex rela- 
tions of the ovary, 21. Sympathy between the cervix and the ovaries. 
Leucorrhcea substituting menstruation. Uterine and vaginal catarrh from 
ovaritis, 22 Barrenness caused by leucorrhcea. The importance of special 
pathology, 23. Indiscriminate cauterization of the os uteri. Intra-men- 
strual treatment, 24. 

Morning Sickness of Pregnancy, and Retroversion, - - 25 

Reflex gastric symptoms in early pregnancy. Retroversion a possible cause 
of morning sickness, 26. Abortion a contingent of retroversion. Morning 
sickness salutary if not excessive. Apt to return at night in retroversion. 
A prognosis of inevitable abortion unwarranted, 27. How to replace the 
womb, 28. The uterine sound as a means of reducing the dislocation. 
Postural treatment, 29. The pessary. Retroversion may persist till 
term, 30. 

On Weaning a Child, and the subsequent treatment of the Mam- 
mary Glands. Galactorrhgea, - - - - - 31 
Fashionable pretexts for the indiscriminate weaning of infants, 32. Ill effects 
of too prolonged lactation. The proper time for weaning, 33. Prophylactic 
treatment. Antigalactics, 34. The age of the child a' criterion of the dan- 
ger of mammary abscess. Local applications, 35. Means of support for 
the breasts. The proper diet, 36. 

LECTURE II. 



Molar Pregnancy — False Conception, - 

Morbid anatomy, 37. Death of the embryo. Influence of age. Retention 
of embryo. Molar pregnancy and menstruation. Probable signs of preg- 
nancy, 39. These signs do not indicate the progress of pregnancy. Cause 
of the delivery, 40. 

Leucorrhcea the Cause of Impaired Lacteal Secretion, 

Leucorrhcea and scrofulosis, 41. Illness of the infant from leucorrhcea in the 
mother. Indirect poisoning of the child, 43. Uterine leucorrhcea and ster- 
ility. Weaning the child. A proper diet. Lymphatic stimulants, 45. 



Too Frequent Menstruation in 

Menstruation aud tuberculosis. 

Significance of the aphonia, 48. 



Incipient Phthisis, - 

Menorrhagia and tuberculosis, 47. 
Season and climate. Mental worry, 49. 



37 



4i 



46 



IV CONTENTS. 

Burrowing Abscess of the Mammary Gland, with a Sinus, 
A domestic expedient. The knife, 51. A good diet, 52. 

Abortion with Misplaced Pains, ----__ 
Abortion from over exertion. Remarkable tolerance of exercise. The 
" habit" of aborting, 53. Intermittent abortion, 54. 



49 

52 



LECTURE III. 

Amenorrhea, with Hysterical Spasms resembling Chorea, - 56 

Difference between suppression and retention. Remote disease from arrest of 
menses, 57. Symptomatic nervous symptoms, 58. Should the flow be 
forced to return. Subsequent trouble from suppression, 59. Rest and 
quiet, 60. 

Abdominal Cramps and Pains in Pregnancy, - - - - 61 

Cramps, etc., after the fourth month, 61. Motion increases the suffering. 
Spurious peritonitis, 62. Diagnosis from cutaneous neuralgia. Character- 
istic symptoms, 63. Uterine colic. Exemption from ovarian disease. Gas- 
tro-intestinal disorders incident to pregnancy, 64. Treatment, 65. 

Excessive Abdominal Development in Pregnancy, - - - 66 

Size of the abdomen as a sign and sequence of pregnancy, 67. The induction 
of premature labor. Pulsatilla in mal-presentation, 70. 

Sudden Suppression of Menorrhagia by Astringents the cause of sub- 
sequent ILLNESS, -----... 70 
Intra-uterine astringents. Menorrhagia sometimes critical, 71. Physiological 
argument against uterine astringents. Digestive disorders from vaginal and 
uterine injections, 72. Menorrhagia from polypi, etc., 73. Intolerance of 
vaginal injections, 74. 

LECTURE IV. 

Uterine Hemorrhage after Twin Delivery, - - - - 75 

Alarming nature of uterine haemorrhage. Incident to rapid labors especi- 
ally. Adherent placenta a cause, 76. Haemorrhage from uterine inertia. 
The haemorrhagic diathesis a predisponent, 77. Signs of danger. Sequelae. 
A qualified prognosis, 78. Internal and local treatment. Obvious indica- 
tions, 79. Available expedients, 80. Stimulants, 82. Value of the binder. 
The compress, 83. 

Pseudo-prolapse of the Uterus, - - - - - 84 

Frequency . of uterine prolapse. Consequence of incorrect diagnosis. 
Unnecessary manipulation, 85. Harmful medication. Spontaneous cures 
and quackish claims. "What remedies may do in prolapsus, 86. Alternation 
remedies, 87. 

Hysteria in a Woman aged Sixty, - - - - - 87 

Hysteria incident to menstrual life. Spasm or convulsions, ? The pupil in 

hysteria. The patient's manner, 88. The pulse. Value of tact. Value of 
impromptu resources. Coffea, 89. 

Procidentia Uteri from Pertussis, - - - - - - 89 

Antagonism of the diaphragm and perineum, 90. Cough a cause of uterine dis- 
placements. Labor a predisponent. Rest, 91. Taxis and reduction, 92. 



CONTENTS. 



LECTURE V. 

Chlorosis, _-.._..__ 93 

Chlorosis and amenorrhoea. Digestive symptoms, 93. Cerebral symptoms. 
Cardiac symptoms. Sympathy between generative organs and the heart, 94. 
The pulse. The anaemic murmur. The appetite. Incidental symptoms, 
95. Menstrual irregularities in chlorosis. Hereditary amenorrhoea, 96. 
Chlorosis and dysmenorrhcea. Chlorosis in pregnancy, etc. Discoloration 
of the skin. The mental state. Etiology, 97. Chlorosis and scrofulosis. 
Blood changes in chlorosis. Haematogenesis, 98. The spanaemia in chloro- 
sis incidental. The nervous theory, 99. Chlorosis preceding amenorrhoea, 
Menstrual complications symptomatic, 100. Diagnosis, 101. Chlorosis 
and jaundice. Chlorosis and anaemia compared, 101. Prognosis, 102. Danger 
from incidental disease, 102. Remedies for general states. Treatment for 
emotional cause. Remedies for the chlorotic cachexia, 103. Iron in chlo- 
rosis. Citrate of iron and strychnia. Wrong to force the menses, 104. 
Spasmodic dysmenorrhcea. Adjuvants. The diet. Exercise and travel, 
105. Amenorrhoea with supra-orbital neuralgia, 106. Varieties of men- 
strual neuralgia, 106. Local peculiarity. Local treatment. Specific treat- 
ment, 107. 

Hysteria at the Climacteric, _..-._ l0 y 

Skin disease and hysteria, 108. Character of the eruption may indicate the 
remedy, 109. 

LECTURE VI. 

Ovaritis, - - - - _ . _ _ _ -no 

The sub-acute form most frequent. Generally symptomatic, no. Ovaritis 
from dysmenorrhcea. From medical and mechanical causes, in. Epi- 
demic ovaritis, 1 12. Traumatic ovaritis. Symptoms. Peculiar pain, 113. 
Exercise. Position Peritoneal ovaritis, 114. The vaginal " touch." 
Characteristic pains, 116. The rectal " touch." The double " touch," 117. 
Feeling of strangulation. Vesical symptoms, 118. Menstrual disorders 
incident to ovaritis. Dysmenorrhcea and ovaritis, 119. Menorrhagia and 
ovaritis, 120. Gonorrhoeal ovaritis, 121. 



LECTURE VII. 

Ovaritis {Continued) — Pathological Anatomy, - 124 

Variation of the lesions, 124. Differential diagnosis between healthy and mor- 
bid ovisacs, 125. Haemorrhage into the ovary. Dropsy as a sequel, 126. 
Liability to suppuration. Character of the pus, 127. Extemporized outlets 
forpus, 128. Enormous quantity of pus formed, 129. Variolous ovaritis, 130. 

Diagnosis. 

Characteristic symptoms. The principle of " exclusion," 130. 

Prognosis, 130. 

The danger from ovaritis after abortion. As a contingent of lying-in. Dan- 
ger from suppuration, 131. Resolution of ovarian tumors, 132. Drain from 
excessive discharge. Consequences of structural change, 133. 

Sequela*. 

Menstrual sequelae, 133. jlmplication of the uterine mucous membrane. 
Sterility from ovaritis, 134. Barrenness from gonorrhoeal ovaritis, 135. 
Nymphomania from ovaritis, 136. 



VI CONTENTS. 

Treatment, 136. 
Of puerperal ovaritis : Belladonna, Colocynth, Veratrum viride, 137. Mercu- 
rius, Hamamelis, Gelseminum, Lachesis, 138, Bryonia, 139. The menstrual 
disorder aiding in choice of the remedy. Of ovarian atrophy and induration, 
140. Of gonorrhceal ovaritis : Calendula. Local treatment. Hamamelis, 141. 
Arnica, Aconite. Protection from cold and dampness. Baths. Pro- 
scribing sexual intercourse, 142. 

LECTURE VIII. 

Bilious Colic during Pregnancy, ------ 143 

The vascular relation between the uterus and the liver, 143. Vascular change 
in the gravid uterus. Bilious symptoms in early pregnancy. The uterus a 
diverticulum, 144. Venous engorgement in uterine affections. Cholestrae- 
mia contingent upon pregnancy and uterine disease, 145. Common influence 
of remedies on the uterus and liver. Symptoms of uterine disorder may be 
remotely located. Bilious colic self-limited. Remedies. Local palliatives, 
146. Prophylaxis. Diet. Mental and physical exercise, 147. 

Prolapsus Uteri, with Superficial Ulceration of the Cervix, - 147 

Uterine luxations beginning at puberty, 148. Irregular menstruation a cause 
of prolapsus. Uterine luxations and digestive disorders. Lumbar and sacral 
pains, 149. Prolapsus and paralysis. Hysterical complications. Reality of 
"nervous" symptoms, 150. Symptoms versus disease. Leucorrhcea and 
ulceration from prolapsus. Ulceration from abrasion. Ulceration without 
inflammation. 151. Causes of uterine abrasion. Nature of ulceration from 
abrasion. Therapeutical reflections. Rule deducible from order of symp- 
toms, 152. Postural treatment. Dressing the hair, etc. Contra-indications 
for the pessary. Prohibition of sexual congress, 153. Modus ope?'andi of 
caustics, etc., in certain cases. Calendula topically. Other local expe- 
dients, 154. 

Pruritus of the Vulva, - - -.- - - 155 

Various causes, 155. Pruritus from trichiasis. Clinical history, 156. Lesions 
from self-inflicted wounds. Preceding the menstrual period. Pruritus with 
dysmenorrhcea and amenorrhcea. At the climacteric, 157. During pregnancy. 
Complication with uterine disease. Limitation to the period of lacta- 
tion, 15S. Topical palliatives, 159. For vulvitis, pediculi, ascarides. Rest, 
diet. Internal remedies, 160. 

LECTURE IX. 

Ovarian Neuralgia. -------- 161 

Peculiar predisponents of ovarian irritation. The neuralgic diathesis, 161. 
The rheumatic diathesis. The hysterical diathesis. Sexual excitement. 
Emotional influences, 162. Organic disease of uterus and ovaries. Mode of 
attack. Kind and degree of pain. Peculiar sensations, 163. Cause of the 
pain. Peritoneal adhesions. Diagnosis, 164. From ovaritis ; from hernia ; 
from uterine neuralgia. Prognosis. Indirect results, 165. Prophylaxis. 
The diet. For the rheumatic complication, 166. Palliatives. Warm appli- 
cations better than cold. Topical expedients, 167. Removal of faecal ac- 
cumulations. Valerianate of zinc. Atropine, 168. Colocynth. Naja. 
Ammonium muriaticum. Ignatia, 169. Cimicifuga, 170. 

Excoriated Nipples, - - - - - - - - 170 

Most frequent in primiparae. Local and general causes. Symptoms, 171. The 
excoriation. The ulceration, 172. Mammary abscess from sore nipples. 
Prophylactics. Need of discrimination, 173. Watching the nurse. For 
simple abrasion. Aphthous ulceration. Linear ulcers, 174. Cleansing the 
nipple. Choice of nipple shield. Precautions. Advantages of the shield, 
175. Treatment of local inflammation. Internal remedies, 176. 



CONTENTS. Vll 



LECTURE X. 

Urethritis, - - - - - - - - - 177 

Causes, 178. Symptoms. Choosing posture. Character of the urine. A 
domestic fallacy, 179. Diagnosis: from stone ; from cystitis; from gonor- 
rhoea, 1 So. Rapid cures exceptional. Rest in the recumbent position. Diet 
and drinks. General indications for treatment, 181. Treatment of gonor- 
rhoea! urethritis. Remedies, 182. 

Membranous Dysmenorrhea, - - - - - 182 

Interesting case, 182. The affection rare, may be overlooked. Causes, 188. 
Anatomical peculiarities of the membrane. Identical with decidua vera, 189. 
Inflammation accidental. Oldham's theory of ovarian influence. Its clinical 
confirmation. Clinical history, 190. Shape and size ot the membrane. 
Regularity of its appearance. Its expulsion, 191. The "flow" proper. 
Reflex gastric symptoms. Reflex cardiac symptoms, 192. Practical deduc- 
tions. Consequent uterine affections. Diagnosis : from abortion. Prog- 
nosis, 193. General therapeutics. Special therapeutics : for rheumatic com- 
plications ; for the abortive dyscrasia, in case of repelled eruptions, 194. 
Reflex symptoms irrelevant. Remedies for the ovarian symptoms. An anti- 
quated prescription, 195. Local applications of temporary benefit. Other 
expedients. The sponge tent, 196. 

LECTURE XI. 

Menstrual Retention a cause of Uterine Displacement, - - 197 

Retention increasing the weight of the womb, 197. Displacements at men- 
strual period. May become chronic, and why. Expulsive effort of the 
uterus. Uterine displacements from temporary suppression, 198. Careless- 
ness at menstrual period. Indications for treatment, 199. Modus operandi 
of most remedies for prolapsus, etc. The sponge tent a useful auxiliary, 200. 

Uterine Colic, -_-.-___- 201 

Vaginal injections sometimes injurious, 201. Symptoms. Duration of the 
attack. Incident to dysmenorrhcea ; to hysteria, 202. May precede men- 
struation. Most frequent among intellectual women. In neuralgic subjects, 
Hygienic and prophylactic treatment, 203. Palliatives. Remedies, 204. 

Post-partum Ulceration of the Womb, - 204 

Likely to be overlooked. A sequel of inflammation, 205. Impaired quality 
of the blood. Weaning the child. The diet. Walking, 206. Riding. 
Cure comparatively easy, and why. Menstruation during lactation. Indis- 
criminate and exclusive local treatment, 207. Only specific ulceration needs 
specific local treatment. Arguments pro and con. Interdiction of coitus, 208. 
Allowable local treatment, 209. 

LECTURE XII. 

Stomatitis Materna: Nursing Sore Mouth, - 210 

Theories of its origin, 210. Limited to gestation and lactation. Peculiar 
lesion, 211. Incidental symptoms, 212. A constitutional disease. Local 
ulceration, 213. Capricious nature of the lesion. Incidental gastric dis- 
order. Causes of the digestive derangement. Diarrhoea, 214. Renal and 
vesical symptoms. The anaemia, 215. Is it cause or effect ? Onset of the 
disease. It may be latent, 216. Qualifying circumstances. The diet, 217. 
Acidulated drinks. Rule for choosing them. Expedients for arresting this 
disease. Premature labor, 218. Weaning the child. Change of climate. 
Medical treatment. The various acids, 219. Case. Arsenicum. Mer- 
curius, 220. Calcarea carb. Ammonium carb. Baryta carb. Natrum nuir. 
Veronica bee, 221. Rhus tox. Local treatment, 222. 



Vlll CONTENTS. 

LECTURE XIII. 

Puerperal Convulsions, .____.. 223 

Case, 224. Relative frequency. Varieties and complications. Exemption 
of epileptic subjects, 225. Hysterical convulsions. Date of commencement, 
During gestation. Influence of delivery, 226. Coming on of the fit. 
Most frequent in birth of male children, and in head presentations. Liability 
of recurrence in subsequent pregnancies, 227. Premonitory symptoms. 
Dropsy a precursory symptom. The convulsive stage, 228. Peculiarities 
of. Brain symptoms, 229. The pulse. Duration and repetition of the par- 
oxysm. Predisposing causes. Exciting causes, 230. Mechanical ori- 
gin. Nervous origin. Reflex causes, 232. The toxsemic theory. The 
albuminuria. 233. Uraemia increases the convulsibility. An exclusive view 
apt to mislead. Physiological deductions, 235. Bright's disease as a con- 
comitant, 236. The hysterical form, 237. The apoplectic. The epileptiform 
variety, 238. 

LECTURE XIV. 

Puerperal Convulsions {Continued), ._-___ 239 
Prognosis. Favorable symptoms. Case, 239. Unfavorable symptoms. Seri- 
ous complications, 240. Forebodings before delivery. Are prse- or post- 
partum convulsions the more dangerous ? 241. Danger to the child. Cause 
of its death, 242. Secondary mental disorders. Paralysis. Peritoneal and 
pulmonary diseases, 243. Amaurosis. Preventive treatment. Tact. Re- 
move possibly exciting causes, 244. Prescribe cheerful society. The physi- 
cian's manner. Early recognition of prodroma. For the insomnia, 245. 
For the cerebral symptoms. For local suffering elsewhei-e. Incipient par- 
alysis. For the dropsical symptoms. 246. For the albuminuria. The 
patient's posture. An available expedient. Caution. Encouragement, 247. 
Palliative treatment. An old rule and a good one. The induction of labor. 
Caution, 248. When justifiable. Ways and means. Note the progress of 
labor. Case, 249. Rupturing the membranes, the forceps. Emptying the 
bladder, case. Faecal accumulation, clots. Cold water, 250. 

LECTURE XV. 

Puerperal Convulsions {Continued), - - - - - - 251 

Anaesthetics. Need of discrimination. Chloroform, hysterical convulsions, 
251. Contra-indicated sometimes, and why. Practical reflections. Danger 
and folly of dogmatising. Case, 252. A good rule. Feel your way. Chlo- 
roform per anum, 253. Practical inferences, 254. Veratrum vir. Case. 
Venesection, 255. Two cases. Domestic expedients, 256. Mustard, dry 
cupping, and camphor. For rigidity of the os uteri and perineum. Rule 
for use of forceps. Exceptions, 257. Case. Applying forceps within cervix. 
Case, 259. Curative treatment, 260. A fallacious dogma. How to give 
the remedy, 261. 

LECTURE XVI. 

Menstrual Headache, __.-__. 262 

Case. Chief symptoms frequently overlooked, 262. Reflex headache, peculiar 
symptoms, 263. Headache from uterine displacement and leucorrhcea. 
Case. Cause of menstrual headache, 264. Proof of connection between 
ovulation and the cephalalgia. Headache from causes which simulate ovula- 
tion. Exciting causes, 265. Search for the primary lesion. Diagnosis from 
" sick " headache, 266. From " neuralgic " headache, from " congestive " 
headache, from "hysterical" headache, 267. Peculiarities of "men- 
strual " headache, the prognosis, 268. Hygienic treatment, 269. Electricity 
and magnetism. Internal remedies, 270. 



CONTENTS. IX 

Prolapsus Uteri with Right Latero-Version, - 270 

Case, 270. Constipation from rectal paralysis. Latero-version from an over- 
loaded rectum, 271. The cramping pains. The vesical symptoms, 272. 
Leading indications. To remedy the constipation, 273. Empty the rectum. 
Restore the uterus, 274. 

Acute Cervical Metritis, .-_._-- 274 
Case, 274. Varieties of. Rare in nulliparae. The monthly cycle a predispo- 
nent, 275. Sewing machines and uterine disease. Causes of acute cervical 
metritis. Mode of operation and results, 276. Differential diagnosis. 
Prognosis. Postural treatment, 277. Remove the cause. Prevention better 
than cure. Items, 278. Local measures. Prescription, 279. 

LECTURE XVII. 

Hysteria, _______-- 280 

Case, 280. Hysteria and the menstrual molimen, 281. During gestation. 
Emotional causes. Possible effects, 282. Case, 283. A practical inference. 
Enigmatical nature of hysteria. Suspicious symptoms, 284. Hysterical exag- 
geration. Incongruous symptoms. Malingering, 285. Secondary effects. 
Leading characteristics. Diagnosis, 286. From valvular disease of the 
heart. Case, 287. From dropsy of the heart, 288. Alleged displacement of the 
heart. The hysterical cough. Case. Diagnosis, from pectoral disease, 289. 
Complications and peculiarities. From asthma ; hysterical aphonia, 
290. From apoplectic aphonia, 291. Gastro-hysterical disorders ; Diagno- 
sis of hysteria from insanity, 292. 

LECTURE XVIII. 

Hysteria, {Continued) - - - ' - - - - 294 

Hysterical delirium. The patient's manner, 294. Aggravated by drugs ; Inci- 
dent to fevers. In child-bed fevers. May be complicated with hypochondria, 
295. Diagnosis of hysteria from hypochondria. Case, 296. The hysterical 
form of peritonitis ; Differential diagnosis of, 297. A suggestive item, 
298. Abdominal tympanites and delirium. Hysteria counterfeiting labor. 
Case, 299. Diagnosis of hysteria from epilepsy, 300. Hysteria or " spinal 
irritation," 302. Hysterical affections of the joints. Diagnosis of. Other inci- 
dental diseases. Nature, 303. Hysteria not a bona fide disease. Its real 
nature unknown. Prognosis, 304. Hysteria concealing graver symptoms, 
305. Treatment. Mental remedies, 306. The real problem. The doctor's 
habits. His personal address, etc., 307. Small items not trivial. Incompat- 
ibility between physician and patient. How to remedy it, 308. Narcotics 
and anti-spasmodics. Hydrate of chloral. Bromide of potassium. Alco- 
holic stimulation, 309. Dogmatizing. Qualified use of stimulants. Proper 
exercise, 310. Hysteria among the " better class." Domestic occupation, 
311. Cultivation of proper mental habits. Domestic infelicity. Content- 
ment. Tact versus Talent, 312. 

LECTURE XIX. 

Treatment of Hysteria, {Concluded) - - - - - 313 

Treatment during the fit. Available expedients, 313. Precaution. Tact. 
Scolding, 314. Taciturnity of patient. Caution in exclusion of symptoms. 
A pathological kaleidoscope, 315. The hysterical diathesis. Remedies to 
counteract it. Coincident menstrual disorders, 316. Study of the legiti- 
mate symptoms. Coincident lesions of the uterus, ovaries, etc. And of 
other organs, 317. Utero-gastric and utero-cardiac derangements. Other 
complications, 318. 



X CONTENTS. 

Irritable Ulcer of the Uterine Cervix, ----- 319 
Reflex relations of uterus and stomach, 319. The speculum not always neces- 
sary. The uterine lesion latent. The protective mucus, 320. Appearance 
of the ulcer. A sign of depraved vitality. Not limited to the poor, 321. 
Treatment. Digestion. Diet, etc. Stop the drain. Internal remedies, 322. 
Local treatment, 323. 

The Differential Diagnosis of Pregnancy, - 323 

Its great importance. Suppression of the menses, 325. An uncertain sign, 
325. Marriage as a remedy. Uterine obliquities, 326. Changes in the 
breasts. Fcetal heart-sound. The uterine souffle, 327. Changes in the 
cervix, 328. 

LECTURE XX. 

The Sponge-tent as a Means of Diagnosis in Diseases of the Bladder 

and Urethra in Women, ____-. 329 

A new use of the sponge-tent, 329. Mode of applying, 330. The tent in 
urethritis. A practical hint, 331. 

Simple Ulcer of the Uterine Cervix, - - - ' - - 332 

Subjective symptoms. Objective local symptoms, 332. Appearance of the 
ulcer. Causes, 333. Treatment, 334. 

The Sequelae of Abortion, ------- 334 

A case, 334. Causes of abortion, 335. Toleration of injuries during preg- 
nancy. Sophistries ■ of the abortionist, 336. Life in the embryo, 337. 
Quickening not the first sign of life. Abortion as a cause of disease, 338. 
Sequelae of abortion. Causes. Constitutional or predisposing. Local or 
organic. Reflex or exciting. Medicinal, 339. Ill effects of wrong diagno- 
sis. Difficulty of recognizing the sequelae, 340. Accidental and spontane- 
ous abortion. Instrumental abortion. Treatment. Rest, 341. Remedies 
Local treatment, 343. 

LECTURE XXI. 

Chronic Cervical Endo-Metritis, or Endo-Cervicitis. Uterine Leu- 

corrhcea, --------- 344 

Extent of the cervical mucous membrane. A glandular lesion, 345. Cervical 
leucorrhcea is not uterine catarrh. Predisposing causes. A sequel of labor. 
Scrofulosis. Menstruation, 346. Tuberculosis. Biliary disorders. Excit- 
ing causes, 347. Symptoms, 348. The puriform discharge. The leucor- 
rhcea merely a symptom. Varying character of the flow, 349. Cervical 
leucorrhcea from other causes. Pelvic pains and sufferings. Burning sen- 
sations, 350. Constitutional effects. Weakness of the eyes, 351. Examina- 
tion with the speculum. Diagnosis. Ulceration incidental, 351. A practical 
hint. The flow not from an ulcerated surface. Diagnosis from cervical metri- 
tis. Prognosis, 353. Treatment. Speedy cures. Removing causes, 354. Need of 
nourishment. Diet. Travel and exercise, 355. Vaginal injections. Topi- 
cal use of glycerine. How to apply it, 356. Calendula, hydrastis, etc. 
Intra-cervical injections. Pessaries, 357. Compression. Escharotics, 358. 
A fallacious practice. Rule for examination of flow, 359. Natural secre- 
tions and abnormal discharges, 360. Practical hints. Remedies for reflex 
ovarian disease. For contingent disorders of menstruation. For utero- 
digestive complications, 361. In utero-pectoral and respiratory ailments. 
In coincident disorders of the circulation. In utero-hysterical and nervous 
complications. For utero-vesical suffering. For utero-rectal symptoms. 362. 



CONTENTS. XI 

LECTURE XXII. 

The Differential Diagnosis of Ovarian Dropsy, ... - 363 

I. — From Ascites, 364. Posture. Consistence of the tumor. The " touch." 
Tapping, 365. Refilling of the sac or cyst. Co-existence of both conditions, 
II. — From pregnancy. Parallel symptoms, 366. A rare case. Location 
and growth. Changes in the cervix, 367. The uterine souffle unreliable. 
The foetal heart-sound unequivocal. Difficulty of diagnosis, 368. Time 
for decision. III. — From uterine fibroids. Haemorrhage, 369. Consent- 
aneous mobility of the uterus and tumor. Length of the uterine cavity. 
Co-existence of the two conditions, 370. Relative rapidity of growth. IV. 
— From fibro-cystic grozvths. Difficulty. Menorrhagia absent, 371. Com- 
parison of symptoms. V. — Fromphysometra. Emptying the uterus. Anaes- 
thesia. VI. — From distention and prolapsus of the bladder, 372. VII. — 
From enlargements of the liver and spleen. Physical exploration. Leucocy- 
tosis. VIII. — From tumors caused by retention of the menses, and of f cecal 
matter, 373. 

LECTURE XXIII. 

Amenorrhea, - - - - - : - - - 374 

Definition. Varieties. 

(1.) Delayed Menstruation. Emansio mensium. Etiology. Delay of 
puberty, 374. Congenital defect. The sequelae of inflammation. Ex- 
ternal conditions. Cachexia. Symptoms. The flow absent, 375. Compli- 
cation with phthisis. Forcing medicine. Diagnosis. Negative signs. 
Caution, 376. Prognosis. An old and true maxim. Treatment. 
Anticipation, 377. 

(2.) Suppressed Menstruation. A practical distinction. Case, 378. 
Hereditary tendency to suppression. Course and frequency. Etiology. 
Avoidable causes, 379. Incident to acute disease. From change of climate 
and travel. From an idiosyncrasy. From trivial causes. From chronic 
disease, 380. Insidious complications. Essentially a glandular disease, 
Ovario-pectoral sympathies, 381. Super-involution of the uterus. Symp- 
toms. Nervous and vascular systems deranged, 382. The amenorrhceal 
cachexia. Diagnosis. From pregnancy, 383. Time. From " change of 
life." Treatment. A cardinal rule, 384. Emmenagogues. Remedies. 
For pectoral complications. For suppression alternating with ophthalmia, 
385. Indications for other remedies, 386. A practical hint. Remedies 
for idiopathic suppression, 387. General treatment. At the month. 

(3.) Retention of the Menses, 388. Etiology. Accidental causes. 
Symptoms. The form without the flow. Diagnosis, 389. Prognosis. 
Treatment.. Surgical means. Dilatation, etc. Reposition of the uterus, 
390. Incision of the cervix. Of the hymen, 391. 

LECTURE XXIV. 

Obstructive Dysmenorrhea, ------- 392 

Definition, 393. Causes. Original conformation. Uterine deviations. Intra- 
uterine growths. Cervical atresia, 394. Cauterization. Symptoms. Uter- 
ine tenesmus, 395. Reflex disorders. Indigestion. Vesical and rectal 
complications, 396. Nervous disorder. Menorrhagia infrequent. Sterility 
from obstructed dysmenorrhoea, 397. Diagnosis. Physical exploration. 
Passing the sound. The flow, and what it signifies. Prognosis, 39S. 
Treatment. Surgical. Dilatation, 399. Introduction of instrument. 
Failure of dilatation, 400. Reported danger from. A barbarous practice. 
Conclusions concerning dilatation. Various kinds of tent, 401. Precautions 
in practicing dilatation. Incision of the cervix uteri. 402. Instruments, 
404. Dangers attending the operation. Precautions, 405. 



XU CONTEXTS. 

Neuralgic Dysmenorrhea, --..__. 405 
Importance of physical exploration, 407. Entire relief by a simple expedient. 
A neurosis. Symptoms, 408. Causes. Relation of the flow to the degree 
of pain. Indications for internal remedies, 409. Warm water. Gelsemi- 
num. Veratrum viride. Dilatation, 410. 

LECTURE XX Y. 

Uterine Surgery ys. Uterine Therapeutics, - - - - 411 

Value of uterine surgery. Extravagant claims. Illustrations. Uterine Thera- 
peutics ignored, 412. Scepticism concerning medication. Old ideas aban- 
doned, 413. Surgery more popular. Therapeutics not to be neglected, 414. 
Study them. Disadvantages of the specialist, 415. A great error. Sur- 
gery and therapeutics. Both essential, 416. New provings by women a 
necessity. Combined effort to increase our knowledge, 417. Study diag- 
nosis. Also pathology, 41S. And pathogenesis. And Symptomatology, 
419. 

Menorrhcea. Cervical Epistaxis, ._-__. 419 
Relation to menstruation. Diagnostic rule. A physiological relation, 420. 

Peculiarity of the flow. Its critical nature. 421. Necessity of physical ex- 
amination. Avoidable causes. Haemorrhage persisting without manifest 
injury, 422. Sterility resulting. Treatment. Medicine versus surgery. 
Different from " unavoidable haemorrhage," 423. General therapeutics. 
For the haemorrhagic diathesis. For the chloro-anaemia. For the scrofulous 
cachexia, 424. For the syphilitic cachexia. For ovarian complications. 
Change of climate. Suitable exercise, 425. Xitric acid, 426. 

Fibro-Cystic Tumor of the Uterus, - 426 

An error in diagnosis. Deceptive symptoms. 427. Differentiation sometimes 
impossible, 42S. Case. 

LECTURE XXYI. 

Aphthous Ulceration of the Os and Cervix Uteri, - - - 431 

The eruptive stage, 431. Symptoms. Diagnosis. Causes. Treatment, 432. 
Reprehensible practice, 433. A constitutional and not a local disease. The 
general health. The vesicular stage, 434. The aphthous condition. Local 
treatment. Astringents, 435. 

Diphtheritic Ulceration of the Os Uteri, - 436 

Constitutional symptoms. Physical symptoms. The pseudo-membrane. 
Depth of ulcer. The discharge, 436. A secondary disease. Cause. 437. 
Remedies. Local treatment, 438. 

Pelvic Cellulitis. Peri-Metritis. Pelvic Abscess, - 

Synonyms. The pelvic cellular tissue, 439. An important suggestion. Fre- 
quency of the disease. Its four stages. The congestive stage. Symptoms, 

440. Intra-pelvic pain. The stage of effusion. Formation of the tumor, 

441. Location of tumor. Symptoms, 442. Course and duration. TJie 
stage of resohition. Sometimes wanting. Conditions promoting resolution. 
The suppurative stage. Symptoms, 443. Accompanying hectic. Seat of 
the fluctuation. Diagnosis of the presence of pus, 444. Its varied means 
of escape. Nature of pelvic cellulitis. Probably allied to erysipelas. 
Causes. Parturition, 445. A sequel to dystocia. A contingent of uterine 
surgery. Coincident disease, 446. Diagnosis. Sometimes difficult. From 
pelvic-peritonitis. 447. Co-existence of the two. From pelvic haematocele. 
From uterine fibroids, 449. Sequela. Relapsing abscess. Sterility. Men- 
strual disorders. Prognosis. The general condition and concurrent dis- 
ease, 450. The epidemic tendency, 451. 



CONTENTS. Xlll 



LECTURE XXVII. 

Pelvic Cellulitis (Continued), - - - - - - -452 

A case. Further symptoms, 454. Treatment. Inferences based on correct 
diagnosis, 455. Pathological deductions. General indications. To pre- 
vent effusion, 456. Aconite. Arnica. Belladonna, 457. Veratrum viride, 
458. Local adjuvants. Remedies for the stage of effusion. Apis mel. 459. 
A good diet. Caution. Stimulants, 460. Emollients. To promote sup- 
puration. Opening the abscess, 461. After-treatment, 462. 

Vaginismus, _-... ... 462 

Symptoms, 463. Local hyperesthesia, 464. Causes, 465. Diagnosis Treat- 
ment, 466. Surgical treatment. Dilatation, 467. Excision of irritable 
tumors. Dr. Tilt's operation, 468. Dr. Sims' operation, 469. Another 
expedient. Local anaesthesia, 470. 

Physometra, .-...__.. 470 

The tumor, 471. Causes. Decomposition of matter retained. Suction of 
air into the womb. Mental causes. Diagnosis, 472. Treatment, 473. 



LECTURE XXVIII. 

Amenorrhcea, with Prolapsus Uteri and Obstinate Vomiting, - - 474 

Prolapsus the exciting cause. Effect of replacing the womb, 476. Subse- 
quent history of case. Practical points. " Totality of the symptoms ;" 
The cardinal symptoms, 477. Practical deductions. Due weight to proper 
symptoms. And proper clinical inferences. A key to success, 478. Ill 
effects of excessive vomiting. Serious nature of utero-gastro-alimentary dis- 
orders, 479. Surgery and medicine not antidotal, 480. 

Irritable Uterus. Hysteralgia, ._...- 480 
No definite lesion. A species of hyperesthesia. Limitation to menstrual life. 
Predisposing causes, 481. Exciting causes, 482. From an early abortion. 
From escharotics, 483. Symptoms. Location of the pain, 484. Effect of 
posture and of motion. Simulating other disease. Nervous symptoms. 
Symptoms capricious, 485. Contradictory nature of symptoms. Physical 
examination. Diagnosis. From coccyodynia, 486. From organic disease. 
From dysmenoi ;cea. Treatment. Removing the cause. Building up the 
general strength. Mode and time of eating. Fresh air and exercise. Vary- 
ing ability to take exercise. A practical hint, 488. Surgerv con f ra indi- 
cated. Topicr.: expedients. No specific treatment, 489. Jsow remedies, 
490. 

LECTURE XXIX. 

The Uterine Sound, -------- 491 

For zvhat purpose employed. In diagnosis. In diseases of the cervix, 491. In 
diseases of the uterine cavity. For measurement. In uterine hypertrophy, 
492 In carcinoma. In tumors. In deviations of the uterus, 493. In 
replacing the uterus. Wheji employed. In the morning. In advance of the 
monthly flow. When the patient is calm, 494. How introduced. Difficulty 
at os internum. Uterine axis not straight. Variation in uterine curve. 
Kind of sound preferable, 495. Position of the patient. An exception. 
Displacement backward, 496. Displacements forward. Speculum and 
sound conjointly. Points to be observed, 497. Mode of introduction. 
Danger from force. Explaining to patient. Choice of a sound, 498. 
" Festina lente," 499. 



X1Y CONTENTS. 

The Climacteric. The Change of Life, - 499 

Crisis in the life of women. Varying age, 499. Duration of Menstrual life. 
Exceptions. Importance of the change. Predisposition incident to this 
period, 500. New disorders induced. Old disorders disappearing. Sym- 
ptoms, 501. Haemorrhage. Simulating pregnancy. Alimentary symptoms, 
502. Disorders of the circulation. Nervous symptoms. Epilepsy, 503. 
Disorders of the special senses. Of the respiratory system. Of the gener- 
ative system, 504. Incidental diseases. Rheumatism and neuralgia. Prog- 
nosis. The best criterion, 505. Cause of the danger. Tuberculous dia- ' 
thesis. Treatment. Hygienic rule. Diversion. Hereditary predisposi- 
tions 506. Remedies. For the tendency to phthisis. For the digestive 
disorders, 507. For disorders of the circulation. For the nervous 
symptoms. For disorders of the generative system, 508. For rheumatism 
and neuralgia, 509. 

LECTURE XXX. 

Spinal Irritation. Notalgia. "Backache,'' - 510 

Case, 510. Resume. Causes. Traumatic. Predisposition by organization. 
Practical inference. A common error, 515. The disease of nervous origin. 
Exciting causes. Symptoms. Injury in sacral region, 515. In the dorsal 
region. In the cervical region. Incidental causes, their centric and eccen- 
tric action, 516. Spinal irritation and uterine disease. Reflex symptoms, 
Ovarian implication. Secondary diseases. Diagnosis. Post-traumatic 
cases, 518. Coccyodynia. Difficulties of diagnosis. Diagnosis from 
inflammation of the cord, etc., 519. Prognosis. Treatment. Itinerant 
patients. Guard the menstrual function. Remove dangerous conditions. 
Tact and sympathy, 521. Remedies. For effects of the spinal injury. For 
rheumatic and neuralgic symptoms. For uterine and ovarian symptoms. 
For contingent disorders. Local treatment, 522. For painful cramping, etc. 
Topical applications. Domestic expedients. Faradization, 524. 

Hysterical Hemiplegia, _-_.___ 524 

Hysterical mimicry. A practical test, 525. Caution. Diagnosis, 526. Other 
differential signs. Position of the arm. Absence of atrophy. Hemiplegia 
and paraplegia, 527. Prognosis. Treatment. Adjuvants. Internal 
remedies. 528. 

LECTURE XXXI. 

Fibroid Tumors of the Uterus, -._-__ 529 
Relative frequency. Pathological anatomy, 529. Homologous growths. 
Number, weight and texture. Varieties, 530. 

1. — Sub-Mucous Fibroids, __-_-._ 530 

Sessile or pedunculated, 531. Symptoms. The haemorrhage. Uterine dis- 
placement. Changes in the cervix. The uterine souffle. Tolerance of the 
tumor, 532. Increased size of the uterus. Physical signs. The " touch." 
Bi-manual examination. Causes. Menstruation and child-bearing. Diag- 
nosis, 533. From ovarian cyst. From pregnancy. From hydatids, 534. 
From fibrous polypi. From inversion of the womb. From retro-version 
and retro-flexion. Prognosis. Sudden death, 535. Symptoms deceptive. 
The risk of an operation. Treatment. Medical. Palliative, 536. The 
sponge tent as a haemostatic. Incision of the cervix. Dr. Atlee's operation. 
Excision of the tumor, 537. Obstacles. Dilatation the first step, 538. 
The ligation of the tumor. A practical hint. Caution. An exceptional 
case, 539. 



CONTENTS. XV 

— Sub-Peritoneal Fibroids, ------- 540 

Frequency, number, size, etc. Symptoms. Chiefly mechanical, 540. Effects 
of pressure. Coincident disorders. Liability to peritonitis. Diagnosis. 
541. From retro-version and retro-flexion. From ovarian dropsy. From 
pregnancy, 542. Relative immunity from abortion. From pelvic 
cellulitis. From impaction of the feces, 543. Course and termination. 
Toleration of the tumors. Cystic degeneration. Prognosis. Nature's 
attempts to cure. No risk of cancer. Treatment. Short comings of 
internal treatment, 544. Reasons. Surgical treatment. Gastrotomy. 
Extirpation of the uterus and ovaries, 5*1.5 . 



LECTURE XXXII. 

Fibroid Tumors of the Uterus, {Continued) 3. — Interstitial 

Fibroids, __.-.____ 547 

Symptoms. Uterine deviations, 547. Dysmenorrhcea. Menorrhagia. Abor- 
tion, 548. Sterility. Diagnosis. The bi-manual examination. Depress- 
ing the uterus. The uterine tenaculum. The sound, 549. Dilatation. 
Prognosis. Relative curability. Influence of the change of life. The 
condition of the cervix, 550. Various forms of degeneration. Treatment. 
Curable in their incipiency, 551. Prophylaxis. Medicinal treatment. 
Belladonna. Lachesis, 552. Sources of fallacy. Local treatment. Sur- 
gical treatment. Enucleation. 553. Dr. Atlee's and Dr. Brown's opera- 
tion. Danger in dilatation, 554. 

Albuminuria in Pregnancy, - - - - - - -554 

Signs of convulsibility. Mercurius corrosivus. Case. 555. No infallible 
prophylactic, 556. 

Ovarian Irritation, - - - - - - - -556 

At the climacteric. Complications. Analysis. Clinical inference. A path- 
ognomonic sign, 557. Exciting causes, 558. A peculiar " thorn in the 
flesh." Remedies, 559. 



LECTURE XXXIII. 



Amenorrhea. Menorrhagia. Convulsions, - 560 

Case, 560. Emmenagogues at puberty, 562. Remote consequences. Men- 
strual intermissions common. Let them alone, 563. The nervous and 
menstrual functions. Illustration. Stopping the flow. A practical distinc- 
tion, 564. The gastric and chlorotic svmptoms, 565. 

Nitric Acid in Uterine IL-emorrhage, - 565 

Metrorrhagia after abortion, 565. Nitric acid as a dernier ressort. Case. 
Clinical deductions, 566. Post-menstrual haemorrhage. Special indications. 
Post-dysmenorrhaeal haemorrhage, 567. Haemorrhage at the climacteric. 
Practical conclusions, 568. 

Chronic Corporeal Cervicitis. Chronic Cervical Metritis, - . 569 

Symptoms. Mechanical. Direct and reflex. Menstrual disorders. Contact. 
570. Nature and cause. Post-puerperal. Bilious complication. Diagnosis. 
From uterine cause, 571. A new diagnostic test. Diagnosis from corporeal 
metritis. Prognosis. Treatment. Postural treatment, 572. 



XVI CONTENTS. 

LECTURE XXXIV. 

Vascular Tumor of the Meatus Urinarius, .... 574 

Case, 575. Nature and location. Symptoms, 575. Physical examination. 
Rule concerning physical explorations, 576. Treatment, 577. 

Latero-Flexion of the Uterus, - - - - - - 577 

Relative frequency of. Causes. Symptoms, 578. Physical signs. Passing 
the sound. Replacing the organ. Postural treatment. Need of courage. 
579. Contingent diseases, 580. 

Spinal Irritation, with Amenorrhcea, Vicarious Vomiting and Con- 
vulsions, --------- 580 

Vicarious haematemesis, 581. Convulsions. The causes of. Prodromata. 
Theories concerning nature of the disease, 582. Cause of the menstrual 
disorder. Failure of dilatation. Incision of the cervix, 583. Practical 
points. A fallacious idea. Dogmatic surgery and medicine, 584. Prog- 
nosis, 585. 

Vulvo-Vaginitis. Prurigenous Vulvitis, - 585 

Intermittent menstruation before the climacteric, 586. Defective ovulation. 
The sudden discharge. Symptoms. The eruption, 587. Its color. Causes. 
Diagnosis from granular vaginitis. From follicular vulvitis. The leucor- 
rhoea, 588. Concerning uterine displacements. Prognosis. Treatment, 
589. Topical. Constitutional, 590. 

Infantile Leucorrhcea, ._.-__. 50,0 

Symptoms, 590. The flow. Causes. Treatment, 591. Local and general. 
Isolation, 592. 

Index, -.-.....__ 593 



LECTURES, 

CLINICAL AND DIDACTIC, 



ON THE 



DISEASES OF WOMEN 



LECTURE I. 

PROLAPSUS UTERI WITH DROPSY, DATING FROM THE CLIMACTERIC 

PERIOD. 

Gentlemen : 

The first case to which your attention will be directed this 
morning belongs to a class of which I shall doubtless have occa- 
sion to speak quite often in my clinical course on the Diseases of 
Women. 

Case. — Mrs. , aged 52, has had four children, the youngest 

of which is now fifteen years old. She has had but one abortion, 
and that occurred prior to the birth of her last child. Her men- 
struation was first established at the age of twelve years, and it 
ceased at forty, that is to say, twelve years ago. She says that 
her mother met with her " change " at the same age. The first 
symptom of ill health that this woman remarked in her own case, 
was a bloated feeling in the abdomen, which was sometimes quite 
full and distended, and again Avould subside to almost its natural 
size. This enlargement, she says, was uniform in its development, 
and not limited to any particular portion of the abdomen. There 
has been no tenderness on pressure, and no soreness. The swell- 
ing is notably increased by exercise, and is accompanied by bloat- 
ing and puffiness of the limbs, the feet, and the face. 

The bowels are habitually constipated, and if she fails to take a 
laxative pill, she has a great deal of straining at stool, and finally 
passes only dry, hard scybala. By reason of this urging at stool, 



18 LECTURES, CLINICAL AND DIDACTIC, 

she is quite positive that the womb is sometimes very much pro- 
lapsed, so much so, indeed, as to threaten protrusion from the 
vulva. She is also certain that at these times she has felt it 
lying between the labia majora. When she lies with the head low 
and the hips raised, the "tumor" disappears. The Dispensary 
Physician, Dr. Streeter, has made a careful vaginal examination 
of this case, and diagnosticates it as one of confirmed prolapsus 
uteri. The swelling of the integument is evidently dropsical, as is 
proved by its " pitting " under the pressure of my finger. The 
urine is scanty and high colored ; the appetite capricious. 

Uterine displacements are so frequently related, either directly 

or indirectly, to abortion and to labor at term, that it will be well 

„ _ . . ( for you, in every case, to inquire whether the 

Parturition a cause ot J ' </ J- 

cUmiteriJperiSd a pre«£- P atient nas recently passed through the process 
poses thereto. £ p ar turition. This woman's last labor oc- 

curred fifteen years ago, and the probability that the uterine 
deviation dates from that event is very much lessened by the fact 
that it was not noticed until three j^ears later. The prolapsus 
came on with the "change," or the advent of the grand climac- 
teric, which, in her case, occurred at the earl}' age of forty years. 
It is, therefore, possible for the uterus to become displaced at the 
end of the child-bearing period, and from other causes than a 
defect in its proper involution, or folding upon itself, after labor. 

Now the most obvious reason why she, at her time of life, has a 

prolapsus so decided, and which is only remotely, if at all, related 

to pregnancy, is the co-existence of dropsy, to 

Dropsy at the climac- ,., ,. n . 

teric, and constipation, which many women are liable at the climacteric. 

causes of prolapsus. ^ 

The ascites and general anasarca are indicative 
of a weakened and relaxed fibre, which strongly predisposes to 
uterine displacements. Add to this the direct pressure imposed 
upon the womb, also the semi-paralyzed condition of the rectum, 
and of the perineum (which has lost its resiliency), and the dis- 
placement downwards, even to the extent of procidentia, is readily 
explained. The only support that the uterus has from below, is 
from the contractile wall of the vagina, which rests like a column 
upon the perineum ; and the chief muscles of the latter are con- 
nected with the rectum and the anus. In the constipation which 
is incident to chronic cases of this kind, the tone and elasticity of 
these tissues is partially or wholly lost. The straining at stool 
may therefore not only serve to perpetuate the luxation, but also 



ON THE DISEASES OF WOMEN. 19 

to change its degree, and even its variety. It may convert a case 
of retroflexion into one of retroversion, or of simple prolapsus 
into procidentia. This relaxed or weakened condition of the 
muscular floor of the pelvis is, as I have already said, much more 
likely to follow upon the heels of labor, either premature or at 
term ; but it also occurs in those who, like this patient, have 
borne numerous children, and who become subsequently afflicted 
with protracted and debilitating disease. 

Treatment. — The relief afforded by the horizontal position, with 

the hips elevated, is significant. Many cases of prolapsus need but 

little beside appropriate postural treatment. It 

the p s e t r , in a e 1 al tr p e ad ment, and often hapP ens that the displaced uterus will 
gravitate into its proper position, if the patient 
can keep off her feet. But it is not always possible, nor would it 
be best, for women with this infirmity to go to bed and remain 
there. Those of the poorer classes must work, and they all need 
exercise. And thus it may become necessary to supply a means 
of support which shall supplement the relaxed muscular fibre of 
the vagina and of the perineum. It is in just such examples of 
prolapsus as this, occurring in women somewhat advanced in life, 
who are ill in other respects, and constitutionally weak, and withal 
obliged to walk and to work daily, that I am accustomed to recom- 
mend the wearing of the perineal pad, as a means of temporary 
relief. It will accomplish more, and is more available in most 
instances, than any other form of supporter. In conjunction with 
the proper internal remedies, its effect is to tone up the parts 
which afford the natural support for the uterus, and at the same 
time to allow the patient to move about with impunity. I shall 
speak, in a subsequent lecture, of the proper indications for pes- 
saries, and the value of them in this and other forms of uterine 
displacement, as they occur under different circumstances. 

It is important that this patient should refrain from all violent 
exercise, more especially from lifting heavy weights, and from 
scrubbing, sweeping, and ironing. She should 
and > i•? i med c ies precauti0ns, not permit herself to strain at stool, neither sit 
in a constrained position for any considerable 
time. Her food should consist largely of albuminous matters. 
designed to improve the quality of the blood ; and of vegetable 



20 LECTURES, CLINICAL AND DIDACTIC, 

substances, particularly of such as are somewhat laxative, as 
fruits, and bread made of unbolted flour. 

The remedies that are most prominently indicated for this 

particular case are mix vomica and apis mellifica. And, since 

neither of them will cover the two sets of symp- 

Internal remedies. . T .. .. 

toms which are present, 1 recommend them to 
be given in alternation, the former at evening, and the latter in 
the morning and at noon of each day. The mix vomica is espe- 
cially indicated on account of the constipation, the straining at 
stool, the passage of scybala, and the threatened escape of the 
uterus from the pelvic cavity. There are the best possible patho- 
genetic and physiological reasons for its employment, although, in 
chronic cases like this, I think it should not be given more than 
once or twice daily. In similar cases, lycopodium, or sepia, will 
sometimes prove of the greatest utility. 

The manifest relation between the commencement of the drop- 
sical symptoms, and the arrest or cessation of the menstrual 
function furnishes us with a characteristic indication for the apis 
mellifica. In using this remedy, my own preference is for the 
second or third decimal triturations. 

LEUCORRHCEA WITH CHRONIC OVARITIS. 

Case. — Mrs. , aged 30, was married seven years ago, but 

has had no children, and has never suffered a miscarriage. She 
has had leucorrhcea for the last ten years. The discharge is of a 
yellowish white color, sometimes thick and creamy, and again 
thin, copious, and quite fluid. After having been upon her feet 
for a long time, the flow becomes more profuse. She is certain 
that the quantity discharged frequently amounts to three or four 
ounces in a day. When the matter which is most liquid escapes, 
she feels most exhausted. She complains, at such times especially, 
of a sense of weariness, and of dragging pains in the loins and 
hips. For a long time, she remarked, the leucorrhceal discharge 
was most profuse either immediately before, or directly after, her 
menstrual " returns ; " but for some time past she could discern 
no especial increase at this or any other period of the month. 

She menstruates regularly every four weeks, but the proper 
flow is gradually lessening in quantity, so that at present she is 
"sick" but two days instead of three, or three and a half, as 
heretofore. The only suffering experienced during menstruation is 
a severe burning pain, which is located just within the anterior 



OX THE DISEASES OF WOMEN". 21 

superior spinous process of the left ilium and above the groin, or 
in other words, in the region of the left ovary. This pain, which 
is sometimes very severe, always extends down the corresponding 
thigh to the knee. She has never had it upon the right side. She 
is quite confident that she has not menstruated a single time, dur- 
ing the last ten or twelve years, without experiencing this peculiar, 
burning, cramp-like, neuralgic pain. When the catamenia cease, 
it immediately declines, and she has never had it in the inter-men- 
strual period. Riding and walking increase its severity. 

Examination by the speculum discloses a scrofulous suppurat- 
ing ulcer at the os externum, extending into the canal of the 
cervix. The mucous membrane, investing the vaginal portion of 
the uterine neck, is considerably swollen and congested. The left 
ovarian region is exceedingly sensitive to external and internal 
palpation. She has been treated by four physicians, three of 
whom cauterized the cervix severely, but without any benefit to 
the patient. Indeed, she steadily continued to grow worse, and, 
as you see, her general health is now very much impaired. 

A chief point of interest in this case is the lesion of the left 

ovary and its consequences. For, the local symptoms which occur 

so regularly, are so characteristic and so constant 

Burning pain in ovaritis. 

Ovulation sometimes a that we are forced to conclude that the ovarian 

constant cause of ovaritis. . . 

disease is the primary one. There is, indeed, 
something quite distinctive about this " burning " pain in the 
inguinal region, which extends down the limb of the same side. 
When it comes on with the return of the catamenia, and ceases 
during the inter-menstrual period, you may be certain that the cor- 
responding ovary is inflamed. This inflammation may exist for 
years, with a brief, sub-acute and self-limited attack each month. 
The cause of this fresh and painful recurrence of inflammation is 
the physiological afflux of blood to the organ ; without this afflux 
the proper function of the ovary can not be performed, any more 
than the gastric juice can be secreted if the delicate capillaries of 
the gastric mucous membrane are not injected with blood. It is 
the periodical repletion of the vessels of an inflamed ovary that 
gives rise to the peculiar, burning, cramp-like, neuralgic pains of 
which our patient has just made complaint, and that has literally 
been the thorn in her side for these many years. 

The reflex relations of the ovaries are numerous, varied, and 

Reflex relations of the important. They are in sympathy with the 

lungs, the mammary glands, the uterine mucous 

membrane, the nerve centers of animal life, and especially with 



22 LECTURES, CLINICAL AND DIDACTIC, 

the uterine cervix and its secretory apparatus. The neck of 
the uterus is not more intimately associated with the womb 
itself, of which it is the natural outlet, than it is with the 
ovaries. These little organs, although remotely located, have 
really as much to do with the active dilatation of the os uteri, and 
the escape of the menstrual flow through it, as they have with its 
first formation in the uterine cavity. They not only serve as 
time-keepers for the menstrual organism, but they also open the 
gateway of the generative intestine for the escape of its periodical 
discharge. 

This peculiar sympathetic function is exceedingly liable to 

derangement. In a state of health, both of the ovaries and of the 

cervix, it is intact. But suppose that either of 

Sympathy between the . 

uterine cervix and the these parts becomes the seat ot serious and pro- 

ovanes. * . , . . . 

tractea disease — nothing is more certain than 
the consequent, although indirect, implication of the other. It 
would be almost, or quite impossible for our patient to have had 
this form of sub-acute ovaritis for so long a period without the 
cervical leucorrhcea also. Protracted and persistent leucorrhceal 
discharges, whether from the uterus or the vagina, or both to- 
gether, are always indicative of structural disease somewhere. 
The lesions which produce them may be idiopathic or secondary. 
They may depend upon causes which are purely local, upon those 
which are constitutional, or upon such as are reflex. In the case 
before us there is little doubt that the ulceration depends on the 
inflammation of the left ovary, which is the fount and origin of the 
disorder for the relief and cure of which we have been consulted. 
The gradual diminution of the menses is significant and sug- 
gestive. When ovaritis is accompanied by uterine ulceration, 

which is not cancerous or phagedenic, there is 
Leucorrhcea may substi- a l m0 st always a tendency in the menstrual 

tute menstruation. J d 

secretion to become more and more scanty. 
Under these circumstances, the leucorrhcea sometimes substitutes 
menstruation, when it is termed " vicarious. " This result is more 
likely to follow the inflammation of both ovaries than of one. 
In catarrhal leucorrhcea, without ulceration of the cervix, and 
uterine and vaginal ca- whether it comes from the uterus or the vagina, 
tarrh from ovaritis. the c ii sc h arge is usually increased either before 

or directly after the catamenial flow. Here the ovarian sympa- 



OX THE DISEASES OF WOMEN. 23 

thy spends itself in giving rise to an extraordinary secretion of 
mucus, and menstruation is more apt to be profuse than scanty. 
Some of the worst forms of menorrhagia, or excessive menstru- 
ation, are engrafted upon this kind of leucorrhcea, which may 
also arise from ovarian irritation and inflammation. 

Sterility is a natural and almost necessary consequence of either 

of the forms of leucorrhcea just named, which 

ieuco" e hffi? s ° aused by m ight> without any great impropriety, be styled 

ovarian leucorrhcea. As our patient's disease 

commenced before her marriage, there are the best of reasons why 

she has never been pregnant. 

Treatment. — It is possible that enough has already been said to 
illustrate the importance of a correct knowledge of special pathol- 
ogy in cases of this kind. And yet I must 
iai T p be thSo° rtance ° f spec " embrace so favorable an opportunity to say a 
few words upon a subject concerning which you 
will find so much in our books and journals. I apprehend that no 
man or woman ever yet made a prescription without having in his 
or her mind a theory of the ailment to be treated. However 
improperly it may have been done, the simplest domestic remedy 
is not given until the disease has been classified. And among the 
fraternity, nolens volens, we are as much addicted to the habit of 
naming diseases before we treat them, as to the naming of our 
babies before they are baptized. And because this theory, which 
represents our idea of the special pathology of the disease in ques- 
tion, and typifies our knowledge or our ignorance of it, is "as 
inevitable as one's shadow," it is vitally important that it be cor- 
rectly established. If we would unravel the tangled skein, we 
must get hold of the proper thread. In order to be skillful and 
successful in the interpretation and cure of diseased states, we 
must begin at the right end of the series. 

According to the theory that the ulceration gave rise to the leu- 
corrhcea, and that what would heal the former would also cure the 
latter, this patient has been cauterized by three physicians in turn. 
Their applications may have patched up the case, but, for reasons 
which you now understand better than they seem to have done, 
the cure was not permanent. The lesion of the os reappeared, 
simply because the ovarian affection had been overlooked and neg- 
lected. And not only did the cruel expedient to which they 



24 LECTURES, CLINICAL AND DIDACTIC, 

resorted fail to cure the lesion of the os uteri ; it also increased 
the ovarian congestion and inflammation. For the sympathy be- 
tween the cervix and the ovaries is snch that whatever harms 
one will almost certainly implicate and injure the other. 

Your preceptors are fully aware of the fact that a large share of 

the ovarian affections which they are called upon to treat have 

been caused in this manner. And your own 

indiscriminate cauteri- f u ture experience will one day confirm the 

zation of the os uteri. -»- ^ 

observation, that the indiscriminate employment 
of escharotics in uterine ulceration is mischievous to the last 
degree. If those three doctors had been more competent diag- 
nosticians, they would have been less likely to commit such an 
unpardonable error in practice. 

Let us endeavor to improve upon this treatment. We must 
study this case most carefully, not for the purpose of naming the 
disease, and afterwards treating it by name, for that plan has 
already been tested ; but to analyze the symptoms presented, and 
to remove them in the most rational and sensible manner. In a 
case of this kind the ovarian symptoms are a thousand times more 
significant than those which pertain to the leucorrhceal discharge. 
The proper plan is, therefore, first to treat the disease of the left 
ovary, and afterwards, if anything remains of the uterine ulcera- 
tion and its consequent discharge, to address our remedies specifi- 
cally to them. 

The prominent sjmrptonis for which we must select a remedy in 
this case are, therefore, severe pain in the left ovan r , which is of a 
burning character, extending down the corresponding limb, which 
recurs with every return of the catamenial period, and is aggra- 
vated by riding or walking ; the menses become more scanty, and 
are accompanied and followed by leucorrhcea. The appropriate 
remedy is thuja oc, of which she will take a dose every evening 
during the month. 

The most proper and effective treatment hi cases of this kind is 

one that is brought to bear during the inter-menstrual period. 

Palliatives and kindred expedients, only de- 

Inter-menstrual treatment. . J 

signed to relieve suffering while menstruation 
continues, are in no sense curative. The persistency of the symp- 
toms just named, and the unequivocal indication presented for the 
thuja, warrant us in promising a great, although, it must be a 



ON THE DISEASES OF WOMEN. 25 

gradual, improvement in our patient's health. In addition to the 
interna] remedy, she should syringe out the vagina twice daily 
with tepid castile suds. In some cases of this kind I add a few 
drops of the crude tincture of thuja, and in others of calendula, 
to the water injected into the vagina. But it should be an indict- 
able offense, for the physician to prescribe or apply astringent 
washes and escharotics, for the relief of such a case of leucorrhcea 
as that to which your attention has now been called. 

You will not understand me to recommend this prescription for 
all cases of ovarian inflammation indiscriminately. Before the ses- 
sion has closed, I shall doubtless have occasion to advise the em- 
ployment of various other remedies in the treatment of this 
disease. 

MORNING SICKNESS OF PREGNANCY, AND RETROVERSION. 

Case. — Mrs. G., aged 85, has reached the third month of her 
fifth pregnancy. Her first two children, a son and a daughter, 
were carried to term and are now living. She has aborted twice 
at about three and a half months, in consequence, as her physician 
told her, of retroversion of the womb. The chief peculiarity of 
the case is that the nausea and vomiting which are incident to the 
early months of gestation are experienced by her at night only. 
It commences each evening at ten, and continues, with occasional 
interruptions, until after midnight, and sometimes until two o'clock 
in the morning. She enjoys her breakfast and dinner, but has no 
appetite for tea. 

She is very confident that when she was pregnant with her two 
living children, the gastric symptoms came on as with most women, 
in the morning and not at night. And also that, in case of the two 
which she lost prematurely, the nausea and vomiting occurred, as 
in the present instance, during the evening and night. For this 
reason she dreads an impending abortion, and is fully persuaded 
in her own mind that it is quite impossible for her to go to " term." 
This conviction is also confirmed by the dictum of her former 
physician, who declared positively that it would be out of the 
question for her to carry her offspring beyond the fourth month. 

Upon careful digital examination, I found an evident deviation 
or displacement of the uterus. The os uteri was nearer the sym- 
physis pubis than natural, and at the Douglas' cul-de-sac there 
was a hard, globular tumor, which yielded to steady pressure in 
the direction of the sacral promontory, and finally passed upwards 
out of reach. This little manipulation afforded her great relief. 
She insists that the replacement of the womb has always palliated 



26 LECTURES, CLINICAL AND DIDACTIC, 

the gastric distress, and sometimes stopped it entirely for days 
together. 

This is an exceptional case. It is seldom indeed that the reflex 
gastric symptoms in the early months of pregnancy are so pro- 
nounced. I have, accordingly, chosen it as 
Reflex gastric symptoms £] ie theme for a few practical remarks. The 

in early pregnancy. *- 

case is a typical one, which illustrates the in- 
timate relationship through indirect nervous communication, 
between the uterus and the stomach. This peculiar sympathy is 
shown in various ways. I have known a patient to vomit within 
five or ten minutes after, and in consequence of the application of 
the nitrate of silver to the uterine cervix. A sudden dropping 
down of the womb in some cases of prolapsus produces the same 
effect. In many cases of tard}^ labor dependent upon rigidity of 
the os uteri, emesis removes the cause of the delay by relaxing 
the cervix. For it often happens that, when delivery has been 
delayed for some hours, the sudden relaxation of the os is announ- 
ced by retching, and a desire to vomit. Ulceration of the cervix 
may indirectly occasion the most intractable vomiting. Bennet 
and others are of opinion that the worst cases of " morning sick- 
ness" are referable to this cause. Uterine displacements are 
known to produce it, and it is more than possible that the slight 
prolapse of the womb, which is incident to the first months of 
gestations, may help to account for this very distressing symptom. 
In the example before you, the retroversion, which is tempor- 
arily induced by more or less of exercise upon her feet during the 

day, and which is relieved when the patient 
causeTm^rSn|s?cknS rests at ni §' ht > is evidently the chief cause of 

the retching and vomiting. When the fundus 
and body of the uterus topple over backwards, they not only press 
upon the anterior sacral or sciatic plexus of nerves, which is 
situated at the side of the rectum, but also upon the sacral ganglia 
of the great sympathetic. The hypogastric plexus is also impli- 
cated in the displacement. The ease with which the organ can be 
replaced, and the manifest relief afforded, are not only useful in 
the matter of diagnosis, but suggestive as to the postural treat- 
ment proper for our patient. For, the mere prescription of a 
remedy, or remedies, to be given internally for the relief of the 
gastric symptoms, is but a fractional part of the physician's duty 



ON THE DISEASES OF WOMEN. 27 

in a case of this kind. It will often happen, that by placing such 
a patient in a proper posture, and regulating her diet, as well as 
the time of eating her meals, and the amount and quality of exer- 
cise taken, we can accomplish more than by the most appropriate 
constitutional means. The cause of the suffering is purely local, 
and the treatment should be partly, if not exclusively, local also. 
In less than a month, if the excessive vomiting and the dis- 
placement do not cause abortion, this woman's womb will pass 
out of the pelvic basin into the abdominal 

Abortion a contingent of . . -, 1 

retroversion of the gravid cavity, m orcier that it may undergo the proper 

uterus. t • 

development. It we can succeed m averting 
the contingency of miscarriage, (which is, perhaps, doubtful,) 
she may go on well to term. For when the womb has escaped 
from the lower pelvis, its liability to dislocation will be removed, 
and the proneness to gastric derangement cease. Provided the 
retroversion is not inveterate, the gastric disorder will be self- 
limited. 

The idea has long been entertained and advocated by obstetri- 
cal writers that, unless a pregnant woman has " morning sickness" 
if not excessive, morn- a ^ some period of gestation, she will be apt to 
Sft t S o C r k e n turn at SghtTii miscarry, or perhaps to have a difficult and 
retroversion. dangerous labor at its close. Although there 

are frequent exceptions to this rule, many persons passing through 
pregnancy from first to last without any particular derangement 
of the stomach, and finally doing well, it nevertheless remains 
true, that its presence is a more favorable sign, if it be not extreme 
in degree or misplaced in the period of its recurrence, than its 
absence. From careful observation in this respect, I am led to 
conclude that the habitual return of this symptom at evening, or 
as sometimes happens, in the middle of the night, renders it a 
more serious and obstinate affair than when it comes in the early 
part of the day, whether before or after breakfast. 

While it is no part of my duty or desire to reflect unkindly 
upon my professional brethren, I must be emphatic in warning 
you against perpetrating the folly and wrong 
a bOTSon S unw a ?rSted! able which this patient's former physician commit- 
ted when he declared it impossible for her ever 
to carry another child past the fourth month. His opinion was 
not properly deduced from the facts of the case, and is, therefore, 



28 LECTURES, CLINICAL AND DIDACTIC, 

fallacious. Because tins poor woman had retroversion in the 
early stage of two successive pregnancies, and afterwards aborted, 
it by no means follows that a third or a fourth, attempt to com- 
plete the process of gestation can not prove successful. If such 
a verdict were as harmless as it were unjustifiable, we would pass 
it by without further notice. But you are witnesses to the fact 
that it weighs down this patient's spirits like an incubus, and dis- 
courages her in the outset. Such dicta are inexcusable and mis- 
chievous. There are few circumstances that will warrant you in 
telling a woman that she cannot possibly go through with preg- 
nancy, and give birth to a living child. Daily experience proves 
that even the most learned and reliable practitioners are likely to 
be mistaken when they pass such a sentence upon their patients. 
The range of physiological possibilities is a wide one, and since 
Nature will do as she pleases, it will be wise in us not to assume 
to limit her powers in this direction. 

Treatment. — The first indication presented is to restore the 

womb to its natural position. This may usually be accomplished 

by a species of vaginal taxis, pressure being 

How to replace the womb. Pin • 

made with one or more of the fingers against 
the body of the displaced organ in the direction of the sacro- 
vertebral angle. In order to be most efficient and least harmful, 
this operation should be performed in a slow and cautious, not in 
a rapid and careless manner. The desired result will be facili- 
tated by calling gravitation to our aid. For this purpose, in most 
cases, it may suffice for the patient to lie upon her side, or better 
still, upon her abdomen. We may, however, find it best to place 
her in the prone position upon the knees and breast, over one or 
more large pillows, as recommended in the treatment of prolapse 
of the funis, and for the correction of presentation of the face, 
side and shoulder. It may also be necessary to introduce the 
finger, or some other instrument, into the rectum in such a man- 
ner as to aid in replacing the uterus. Gariel's air-bag may be 
passed into the bowel behind the displaced organ, and afterwards 
so inflated as to lift the fundus, and compel the womb to corre- 
spond as it should with the axis of the superior strait. Or you 
may employ this little instrument, devised by my friend, Prof. 
Guernsey,* which is admirably fitted to fill the same indication. 

* Vide Guernsey's Obstetrics, etc., 1867 ; page 16. 



ON THE DISEASES OF WOMEN. 29 

In using this instrument, Dr. G. recommends that, after the 
bladder and rectum have been emptied, " the patient should be 
placed on the bed, near its edge, upon her knees and elbows, so 
that the force of gravity may assist in the reduction. The ball of 
the instrument, well lubricated, is to be brought to the anus, with 
the convex surface of the rod upwards, then gently pressed until 
within the sphincter ; when the handle should be slightly elevated, 
so as to bring the ball against the anterior wall of the rectum. 
The instrument is now to be firmly and carefully pressed up the 
rectum, when the ball will elevate the fundus, — care being taken 
to raise the handle more and more as progress up the rectum is 
made ; and presently the uterus will regain its normal position 
immediately posterior to the symphysis pubis. 

In all cases of uterine displacement incident to pregnancy, and 

whether for purposes of exploration or of treatment, you should 

carefully abstain from the introduction of any 

The uterine sound as a. 

means of reducing the dis- instrument whatever through the canal of the 

location. > # ° 

cervix into the uterine cavity. Such an opera- 
tion would be almost certain, sooner or later, to be followed by 
abortion. And I natter myself that no member of this medical 
class would willingly commit the crime of murder, even for the 
sake of curing a case of prolapsus, or of retroversion of the womb ! 
I have known a physician, however, who, through cupidity and 
ignorance, found it convenient to diagnosticate many examples of 
the latter displacement in pregnant females, and afterwards to 
reduce the dislocation by means of the uterine sound — a most 
cruel and unwarrantable expedient. 

But simply to replace the organ in such a case as the one before 
us is not always sufficient. Unless we provide against a recur- 
rence of the displacement, more especially when 

Postural treatment. . .,..,. 

the patient assumes an upright position, the in- 
creased size and weight of the womb will bring it down again. 
To obviate such a result, and thus indirectly to control the gastric 
symptoms, she should remain in the horizontal position upon the 
bed or sofa, and should lie either upon the side or upon the abdo- 
men. If she can keep off her feet altogether until such time as 
the uterus has ascended into the abdomen, the vomiting will be 
greatly relieved, and perhaps cured, and, what is still more im- 
portant, the chief danger of abortion will also be averted. 

It is only now and then that a pessary is of real utility in the 



30 LECTURES, CLINICAL AND DIDACTIC, 

uterine deviations contingent upon pregnane}'. The watch-spring 
pessary, covered with rubber, will sometimes 
answer a good purpose temporarily, and is less 
objectionable than most others. Either of the stem pessaries 
would be more likely to cause than to prevent a miscarriage, and 
moreover they are not suited to cases of retroversion. 

In two similar instances I have succeeded in keeping the womb 
in situ by the introduction of a small sized air-pessary, to be then 
inflated, into the posterior and superior portion of the vagina, in 
such a manner as to prevent the body and fundus of the organ 
from falling towards the coccyx. When distended with air, this 
rubber bag becomes a species of cushion against which the uterus 
may rest without injury, and indeed it can do no possible harm to 
the soft parts. Nor is it half so liable as instruments that are made 
of more solid materials, to stimulate reflex uterine contractions, 
and thereby to excite an abortion. Some practitioners prefer 
Hodge's lever pessary in this as in other cases of retroversion. If 
judiciously used, it very rarely happens that the means which I 
have indicated will not serve to replace the womb and to keep it 
in position. A few cases are recorded in which the displacement 
has persisted until the end of gestation. Where 
Retroversion may persist j-\ 1Q retroversion is inveterate, and in case of 

until term. 7 

emergency, it has been thought expedient some- 
times to promote the evacuation of the uterine contents by ruptur- 
ing the amniotic sac through the uterine cervix, or by the opera- 
tion of paracentesis uteri, as first recommended by the celebrated 
Dr. William Hunter. 

In a report upon the retroversion of the gravid uterus, read 
before the Obstetrical Society of London, by Dr. W. Tyler 
Smith,* you will find the following instructive case : 

" I was consulted in August, 1859, by a lady, a patient of Dr. 
Duigan, of Gainsborough. She was the mother of two children, 
and, in the previous May, had a miscarriage, which left her in a 
very weak state. She had lost blood largely, and had since been 
irregular at the periods. Her chief complaint was of a distressing 
pain at the bottom of the back, and the least attempt at walking 
or exertion produced faintness. On making a digital examination, 
the uterus was found to be retroverted, the fundus hanging upon 
the lower part of the rectum, and so enlarged as to make me be- 

* Trans, of the Obstetrical Society of London ; Vol. II., page 297. 



ON THE DISEASES OF WOMEN. 31 

lieve that pregnancy existed. She remained in town about a 
month ; and the increase in the size of the uterus in this time con- 
verted the "belief into certainty. There is no other condition in 
which the increase of the gravid uterus in the early months can 
be so readily estimated as in retroversion. The globular fundus 
is so perfectly within reach of the finger, as to render it possible 
to measure its increase with a precision which cannot be obtained 
when the uterus is in its natural position. In this case, the fundus 
could be lifted from the rectum, so as to afford temporary relief, 
but it would soon return to the position of retroversion. Acting 
on this hint, I introduced an air-pessary of considerable size, which 
gave great relief, and enabled her to move about to an extent 
which had previously been impossible. With the air-pessary the 
uterus remained in a state of semi-retroversion. She continued 
to wear the instrument, with great comfort, for upwards of two 
months, and only left it off when quickening and the movements 
of the child made it certain that the uterus had risen out of the 
pelvis. She was delivered in April last of a living child, and 
carefully rested after her confinement, lying, as much as possible, 
in the prone position. In this case, the pelvis was of large size, 
and it is the only instance I have seen of persistent retroversion 
in the gravid state, in which there was no vesical symptom what- 
ever. I have seen this patient twice since her delivery. The first 
time there was no sign of retroversion, but the second it had re- 
turned to some extent, and I advised the use of the air-pessary 
again." 

ON WEANING A CHILD, AND THE SUBSEQUENT TREATMENT OF THE 
MAMMAE Y GLANDS — GALACTORRHEA. 

Case. — Mrs. Z , aged 30, applies for advice concerning the 

propriety of weaning her child, and likewise for instructions rela- 
tive to the best method of procedure if this expedient is deemed 
proper. The baby is eleven months old, and healthy in every 
respect, not having had a day's sickness from its birth. The 
mother's health is also excellent. The milk is furnished in good 
amount and quality, and although she really dreads to wean the 
little one, she will nevertheless do so if it is thought best. By 
the advice of her former physician she nursed an elder child, now 
four years of age, until it was' eighteen months old. Her infant 
feeds well, and, if it were allowed, would eat almost anything. 
It has a mouthful of teeth. She fears that when she takes it from 
the breast altogether, she may have trouble with the glands them- 



32 LECTURES, CLINICAL AND DIDACTIC, 

selves. For she is somewhat peculiar in this respect, that with 
her the milk continues to be secreted for a long time after it has 
ceased to be regularly drawn off. Thus when she weaned her 
little girl, two years and a half ago, the milk " continued to come 
into the breast," as she says, for four or five months longer, her 
menstruation being quite regular meanwhile. And following an 
abortion, that she once experienced at the fourth month, she had 
a considerable flow of milk for the space of nearly six months. 
For this reason she feels exceedingly anxious to know what course 
is the proper one. 

In the practice of your profession you will be frequently con- 
sulted in cases similar to this. You will observe that some mothers 
apply for professional sanction to wean their 

Fashionable pretexts for " 1 , . , -■ , p , 

the indiscriminate weaning children early, and, indeed, that many 01 tnem 
prefer not to nurse their babies at all. These 
most unnatural and baneful practices are, unfortunately, becom- 
ing more frequent. In all our cities and towns — and in these 
days of railways and telegraphs there are no more country villages 
— the custom of rearing children at second-hand, or by proxy, is 
becoming more and more popular and prevalent. The most silly 
pretexts are preferred by people in fashionable life for denying the 
little infant the mother's breast. One such mother will decline to 
ruin her bodily form and figure by nursing her own child, another 
considers it vulgar, a third is too much of an invalid herself, while 
a fourth is unwilling to sacrifice the pleasures of the table, of the 
toilet, or of gay and fashionable society, of late hours, or of some 
favorite form of dissipation, for the cares and crosses of maternity. 
Among women of the great middle class of society there is a grow- 
ing aversion to what is both natural and necessary for the welfare 
of their delicate offspring. For the most trivial, and even shame- 
ful reasons, too many little innocents are thus denied their most 
appropriate aliment. The consequence is that a large share of 
American mothers never experience those reflex influences that 
would tend to soften and sweeten their own natures ; and that 
thousands of children are poisoned by all sorts of artificial substi- 
tutes for healthy human milk. 

Another class of mothers place a premium on the luxury of nurs- 
ing their own children. They are never quite ready and willing 
to wean them. If your future observation accords with my own, 
you will have reason to conclude that, with many members of this 



ON THE DISEASES OF WOMEN. 33 

class, the pleasure derived from the performance of this very natu- 
ral function constitutes the chief enjoyment of their married life. 
Not unfrequently, however, there is another reason for the re- 
solve on the part of these women to prolong the period of lactation. 
As a rule, menstruation is suspended until the 
in effects of too prolonged ^1^ i s taken from the breast. This they all 

lactation. «/ 

know as well as we do. They are also aivare 
that, while the nursing woman does not menstruate, she is not 
very likely to conceive again. Hence many mothers voluntarily 
continue to suckle their children beyond the proper time, in the 
hope that they may thus avoid too rapid an increase in the family. 
But since there are many exceptions to the rule that a nursing 
woman may not become pregnant, and more especially because the 
health of the child, and of the mother also, may be injured thereby, 
it will become your manifest duty, in some cases, to insist that 
this practice shall be relinquished. 

As a rule, if both the patient and her child are well, the little 
one should not be weaned before it is about a year old. After this 

period the mother's milk becomes deficient in 
^The proper time for wean- casein, — a physiological reason why lactation 

should not be prolonged. In deciding upon the 
most proper time for taking the children from the breast, something 
depends upon circumstances. If, for example, the little thing has 
cut its teeth freely and early, and manifests a disposition for a 
mixed diet, being ready and eager to eat almost anything that is 
offered, there will be little risk in weaning it. It will, however, 
be more safe for the child to cease nursing in cool or cold weather, 
as in the fall or winter, than in the late spring or early summer 
months. If a severe epidemic, more especially any alimentary 
disorder, such as cholera infantum or dysentery, is prevalent 
among young children, you should counsel the mother to wait 
until the epidemic has subsided before she puts her child away. 
The almost utter impossibility, in our larger cities, at certain sea- 
sons, of procuring good, healthy cow's milk for the infant, may 
afford another valid reason for prolonging lactation even beyond 
the twelfth month. Statistics prove that after the ninth month, 
weaning is more apt to be followed by mammary abscess than at 
any period between the second and ninth months. 

In the case in which we have just been consulted, the child's age 
3 



34 LECTURES, CLINICAL AND DIDACTIC, 

is favorable, it has its complement of teeth, eats well, and is 
thrifty in every regard ; the season (November) is propitious ; 
and there is no disease which at this time is especially prevalent 
among infants and young children. We therefore advise that 
this woman's babe be weaned. 

Treatment. — And now the question is fairly before us ; what 
course is most proper for the mother ? In her case there is a man- 
ifest predisposition to a profuse and prolonged secretion of milk. 
Ordinarily the quantity of milk secreted is in proportion to the 
frequency with which the breast is drawn, or emptied ; the more 
it is nursed, the greater the yield. But in this case a profuse flow 
is furnished by the gland, although none of the product is forci- 
bly withdrawn. Here there is a danger lest the milk may accu- 
mulate and give rise to inflammation, and, ultimately, to mammary 
abscess. Hence we must, if possible, institute measures that will 
avert such a calamity. For it is a species of martyrdom for any 
woman to suffer from an abscess or abscesses of the mammary gland, 
and we should use our best endeavors to spare her such an infliction. 

"Where, as in this instance, the flow of milk is very profuse, 

and especially if the child is several months old, I think the wiser 

course is to wean it gradually — say to nurse 

Prophylactic treatment. . . ° "i ^ 

it only at night for a time, and to feed it dur- 
ing the day. This plan will prevent the accumulation of a very 
large quantity of milk in the breasts, and also allow the general 
organism to accommodate itself to the new condition of things, 
points which are in some cases most significant. If the mother 
stops nursing abruptly, there will be greater risk of local trouble, 
and of a general derangement of her health, than if the change is 
less sudden and extreme. 

This rule, which has its exceptions, is also applicable in case it 
becomes necessary to wean the child at a very early age. In gen- 
eral, however, it is thought advisable to put the infant away from 
the breast at once, as less troublesome than gradual weaning. 
Afterward, if the ducts become obstructed, and the glands dis- 
tended, hard and painful, a resort is to be had to some artificial 
means of emptying them, and of averting farther trouble. 

Medicines which are believed to have the power of lessening 
. . , . the quantity of milk secreted are termed Anti- 

Antigalactics. , ~ 

galactics. They are used both internally and 
externally. Of those which are adapted to internal use the more 



ON THE DISEASES OF WOMEN. 35 

prominent are belladonna, biyonia, calcarea carbonica, and phos- 
phorus. Besides these, other remedies are suited to lessen a redun- 
dancy of this flow, when it is attended by peculiar symptoms, all 
of which are lacking in this case. For, Mrs. Z. is not ill at the 
present time, and the most diligent search might fail to disclose a 
single symptom of an abnormal condition. Our treatment must, 
therefore, be prophylactic. It should be designed so to diminish 
the quantity of this secretion as to insure the breasts against local 
disease or injury, and the general system from all contingent dis- 
orders. To fill this indication I have more confidence in the cal- 
carea carbonica than in any other remedy. I prefer it in the 
third decimal trituration. Your future experience may cause you 
to decide in favor of some other form or potency of this remedy. 
This is a matter which cannot be settled for you in the lecture-room. 
In general, the younger the child the greater the danger of 
mammary abscess from weaning it. There are, however, excep- 
tions to this rule also, in which it is almost or 

The age of the child a . 

criterion of the danger of quite impossible to take the child irom the 

mammary abscess. 

breast at any period without incurring the risk 
of this accident. When a physician tells you that he has always 
been able to avoid such a result in his practice, you may safely 
conclude that he has been unusually fortunate, or that his obser- 
vation has been limited. 

Local adjuvants are not only admissible, but, in certain cases, 
necessary also. Most practitioners prefer camphor for this pur- 
pose. Cloths may be wet with the common 

Local applications. . • _ _. •- _ 

tincture and applied directly to the breast. Or 
it may be anointed with a mixture of camphor and sweet oil — 
the camphorated oil of the shops. A saturated solution of cam- 
phor in glycerine makes a more pleasant and equally useful prep- 
aration, which may be kept constantly applied over the gland by 
means of flannel compresses. 

Several of my medical friends assure me that they have derived 
the most satisfactory results from the topical employment of cold 
water, as a preventive against mammitis and mammary abscess in 
cases of this kind. I have no experience therewith. They recom- 
mend to apply a wet compress directly over the gland, and to pro- 
tect the clothing by a dry one outside. This is to be renewed 
from time to time, the water being at the temperature of ordinary 



36 LECTURES, CLINICAL AND DIDACTIC, 

well or hydrant water. They claim that the faithful use of this 
simple means will spare much subsequent trouble to all concerned. 
Another method consists in covering the breast with one or more 
layers of flannel, and then applying a bladder which is partly 
rilled with broken ice. Persistent rigors and chilliness, however, 
contra-indicate the use of cold applications of all kinds. 

A stimulating lotion may also be made of black pepper {Piper 
nigrum')^ by permitting it to stand for a considerable time in good 
brandy. The pepper should, however, be in the grain and not 
ground, or pulverized, otherwise, by insinuating itself into the del- 
icate skin, especially in the region of the areola, it might occasion 
much suffering. This lotion may be applied in the same manner 
as recommended for the glycerole of camphor. 

In inflammatory cases in which the pain and throbbing of the 
gland are severe, or if the pains are neuralgic, the application of 
the belladonna plaster will sometimes afford the greatest possible 
relief. It may serve not only to abort the suppurative process, 
but also to put a stop to the further secretion of milk. This 
expedient seems especially adapted to those cases in which it is 
advisable, directly after labor, to institute measures for the preven- 
tion of a free flow of the lacteal product. Dr. Marley recommends 
to smear the breast with the extract of belladonna.* He has em- 
ployed this treatment for the prevention of mammary abscess 
with almost uniform success in 44 cases, in which a prompt arrest 
of the lacteal secretion was necessary. 

When the breasts are large and flabby, the extra weight may be 
relieved by a broad handkerchief, a net- work supporter, or by 
strips of adhesive plaster properly applied. 
brelst a r° fsupp0rtf ° rthe These plaster-strips are sometimes used to 
secure uniform compression of the glands, and 
thereby diminish their secretion. The bandage of Seutin has been 
extolled for the same purpose. 

Our patient should abstain from soups and all kinds of liquid 

food, and satisfy her appetite chiefly with solids. It would not 

be best for her to drink largely of any fluid 

I he proper diet. o %i j 

whatever, more especially of water or malt 
liquors. She will take a dose of the calcarea carbonica every 
night, and apply the camphorated oil externally. 

* Transactions of the Obs. Society of London. Vol. I., p. 31. 



ON THE DISEASES OF WOMEN. 37 



LECTURE II. 

molar pregnancy — false conception. 

Gentlemen : 

In my obstetrical course you were told that, in forming a cor- 
rect diagnosis of pregnancy, an exclusive reliance upon any of its 
presumptive or of its probable signs would be likely to mislead 
you. I will open my lecture this morning with a case in point, 
the counterpart of which, in some respects at least, you will surely 
meet with as medical practitioners. 

Case. — Mrs. W , aged 42, was married eight months ago. 

She was at that time a widow • but had never had any children. 
She says that within the eight months, or since her last marriage, 
she has not menstruated. Prior to that, menstruation was normal 
in every respect. She has had no vicarious haemorrhage, or leu- 
corrhoeal flow. When the menses ceased she began to have 
morning-sickness, which continued for six weeks. She had also 
various caprices of the appetite, with faintness before dinner, and 
inordinate craving for food. There was no perceptible develop- 
ment of the ovum, or enlargement of the abdomen. The mammae 
became swollen and sensitive. 

Six days ago, after walking to church upon the icy pavement, 
she began to " flow." The haemorrhage from the uterus was pas- 
sive, irregular, and slight, until the third night, when, after having 
had a great deal of pain about the back and loins, with some head- 
ache and debility, she awakened out of sleep very much fright- 
ened by the escape of a fleshy mass from the uterus and vagina. 
The flowing soon ceased, and to-day she has ventured to walk to 
the Clinique. In addition to the details already given, she says 
that all her unpleasant and indescribable feelings about the hips 
and abdomen were greatly relieved by a bandage worn tightly 
about those parts. 

This was an example of spurious pregnancy, sometimes styled 
false conception, pseudo-pregnancy, quasi-^es- 

Morbid anatomy. r Jr . -, , ,11 

tation, molar gestation, and should not be con- 
founded with pseuclo-cyesis. The product was a fleshy mole, which 



38 LECTURES, CLINICAL AND DIDACTIC, 

the patient has preserved, and brought with her, and which we 
will now proceed to examine. Fortunately for us, she has kept it 
in water, and the examination will not be difficult. You will ob- 
serve that the mass is about the size of a small lemon. On cutting 
through its walls, we come down to the amnion, which is intact. 
Slitting this open, a slight flow of its proper liquor escapes. Here 
is the rudimentary embryo, which, although it has been eight 
months in utero, is not larger than it should have been at the 
sixth week of pregnancy. The undeveloped funis is but a mere 
thread, and ragged at its free extremity. Between the outer 
membranes, or rather within the thickened wall outside of the 
amnion, blood has been effused, and small coagula are seen. 

These appearances indicate an arrest of embryonic develop- 
ment. Conception probably took place as it should have done, and 
all went on well for a limited period. But, for 

Death of the embryo. 1 . . 

some unknown reason, the nourishing supplies 
that were derived from the uterine surface, and designed for the 
ovum, were appropriated to the abnormal, pathological growth of 
the chorion. The little embryo was therefore sacrificed. It died 
from a lack of those elements which were necessary to the devel- 
opment and repair of its tissues, and the hypertrophied chorion 
and decidua constitute this carneous or fleshy mass which is called 
a mole. 

Although women of all ages are liable to this form of spurious 
pregnancy, yet it is a singular fact, that those who have reached 

their fortieth year seem more prone to it than 

Influence of age. x 

those who are younger. As in the case before 
us, it is not uncommon among women who marry a second time 
late in life. The formation of these moles (which are the conse- 
quence, not the cause, of the death of the ovum) is intimately 
connected with the history of abortion. Rigby says most expres- 
sively : " AVhen any cause has occurred to destroy the life of the 
embryo, during the early weeks of pregnancy, one of two results 
folloAvs, either that expulsion takes place sooner or later, or the 
membranes of the ovum become remarkably changed, and con- 
tinue to grow for some time longer, until at length they form a 
fleshy, fibrous mass, called a mole, or false conception." 

The true mole is always a product of conception. When the 
mass has been expelled, it is not difficult to recognize it, and to 



ON THE DISEASES OF WOMEN". 39 

separate it from spurious formations which resemble it in some re- 
spects, by the presence of a rudimentary embryo 

Retention of embryo. .... ., ., T ~ , ,, , 

within its cavity. 11, however, the embryo 
died during the first month, it may have been dissolved, and we 
shall, therefore, fail to find it on dissection. Such a mole may be 
retained within the uterus for many months, or it may be cast off 
and expelled at or about the period at which the menses should 
hrve returned had the woman not been pregnant. It sometimes 
happens that the haemorrhage attendant upon labor of this kind 
is profuse and long-continued. Generally, however, it ceases with 
the delivery of the fleshy mass. Ambrose Pare cites a case in 
which a mole was retained in the womb for seventeen years. 

Among the clinical points worthy of note in the case before us, 
you will observe that, until her last marriage, this woman's men- 
struation was habitually regular and healthy. 
meistrSaS nancy and ^ * s important to take this fact into account, 
for it sometimes happens that menstrual disor- 
ders predispose to abnormal developments of the membranes 
which enclose the ovum. Membranous dysmenorrhcea may indi- 
rectly cause this form of spurious pregnancy. 

Following the arrest of the catamenia there was no vicarious 
discharge. Morning sickness set in, and our patient was sup- 
posed to be pregnant. This continued for six 
nanc° bablesIsns ° fpreg " wee ks, or most probably until the death of the 
embryo, and was accompanied by the capricious 
appetite, fainting, etc., to which so many women are liable after 
conception. 

For the best of reasons there was no observable change in the 
abdomen. The usual development of the uterine tumor was pre- 
vented. There was no necessity for the womb to ascend out of 
the pelvis, as it would have done had gestation gone on properly. 
The embryo was dead, and its growth became impossible. The 
uterine cavity was already large enough to contain it, and hence 
there was no need of its further expansion. If the case had been 
one of hydatids (falsely so-called), the abdominal enlargement 
might have taken place. For these hydatigenous growths some- 
times fill the womb, and cause it to enlarge in very much the 
same manner as if it contained a healthy foetus. They may also 
be retained even some months beyond "term" before they are 



40 LECTURES, CLINICAL AND DIDACTIC, 

finally expelled. You should not forget that these uterine hyda- 
tids are really due to a defective organization of the placenta, or, 
more properly speaking, to a cystic degeneration of the villi of the 
chorion. 

We have no means of knowing the precise changes that took 
place in the breasts in this case. It is possible that the areolae 
may have been discolored, and the follicles about the nipples de- 
veloped, as in true pregnancy. These glands are liable to become 
swollen and sensitive from other causes, and this general symp- 
tom of pregnancy would therefore be very uncertain and unreli- 
able. At this time there is nothing peculiar in the appearance of 
the mammary glands. Usually, in similar cases, the series of 
changes proper to these organs, and which provides for the extra- 
uterine needs of the infant, is arrested when, from any cause, the 
embryo dies. Even when the mole or the hydatid mass is carried 
to the ninth month, or beyond, before it is extruded, there is gen- 
erally little or no secretion of milk. 

From these remarks you will infer that, although the suppres- 
sion of the menses, the morning sickness, and the fickleness of 
appetite, are to be regarded as presumptive 

These signs do not indi- . . . 

cate the progress of preg- signs, of conception, and may signity that the 
fecundated ovum has reached the uterine cav- 
ity, and commenced to develop therein, still they do not afford a 
certain criterion of the progress of gestation. They may have 
marked its commencement ; but do not indicate its possible arrest 
or failure. This patient had the morning sickness during the 
first six weeks, but afterwards the only remaining symptom of 
pregnancy was the non-appearance of the menses. And the pro- 
longed arrest of this flow is to be accounted for by the presence 
of this foreign body, or mole, within the womb. 

Concerning the final cause of labor in this form of pseudo-preg- 
nancy, various theories have been advanced. Perhaps the most 
reasonable is that which refers it to the men- 

Cause of the delivery. . . 

strual cycle, when the physiological afflux of 
blood to the uterine, mucous membrane facilitates, if it does not 
actually insure, the entire separation of the decidua. At this par- 
ticular period the cervix uteri is also more or less relaxed, as if 
menstruation were coming on, and some slight exciting cause, as, 
for example, a fall, or sudden shock, or forcible exercise, as in. 



ON THE DISEASES OF WOMEN. 41 

walking on an icy pavement, may precipitate labor. Dilating 
pains follow or accompany the haemorrhage. In due time expul- 
sive contractions set in, and the womb is emptied of its contents. 
The suffering may be either slight or severe, its quality and 
degree varying with the laxity of fibre of the uterine neck, the 
rapidity of the labor, the size of the mole, and the temperament 
of the patient. It is only in exceptional cases that the mass drops 
away with so little pain as this patient had. Although there are 
women who frequently and habitually suffer from this form of 
spurious pregnancy, it does not follow that one such mishap is 
certain to be succeeded by a second of a similar kind. Even at 
her age, Mrs. W. might, perhaps, pass through another pregnancy 
successfully. 

LEUCORRHCEA THE CAUSE OF IMPAIRED LACTEAL SECRETION. 

Case. — Mrs. , aged 30, of scrofulous diathesis, has one 

child, which is now two and a half months old. She has had 
leucorrhcea for more than two years. It showed no abatement 
during pregnancy, and continued through her lying-in and lacta- 
tion. At birth, her infant weighed ten pounds ; now it weighs 
only eight pounds. Its digestive system has been constantly 
deranged, and its little life threatened by vomiting, indigestion, 
and diarrhoea. The mother's breasts have not been diseased in 
any way, but have remained plump, soft, and natural. The qual- 
ity of the milk, however, was impaired. It was thin, watery, and 
of a bluish cast. 

A fortnight ago the child was, by my advice, taken from the 
breast, and ordered good cow's milk, diluted in the proportion 
of one-third water to two-thirds milk. Immediately it began to 
improve and gain flesh, and it is now nearly well. The only 
treatment this patient has ever had for the leucorrhcea, consisted 
of harsh astringent injections of alum-water, tannin, etc. These 
expedients have had the effect to arrest the flow temporarily. 
She describes the discharge as milky, and says it is accompanied 
by more or less of aching in the vagina and itching of the pudenda. 
The flow is more profuse after exercise. It has been her habit 
heretofore to menstruate too freely and frequently. 

Leucorrhcea is sometimes very persistent. It may be associated, 

either as cause or effect, with a depraved and 

Leucorrhcea and scrofu- enfeebled condition of system. The worst cases 

losis. 

occur in scrofulous subjects. In this class of 
patients there is a strong predisposition to glandular disease, and 



42 LECTURES, CLINICAL AXD DIDACTIC, 

leucorrhcea should properly be classed among the glandular affec- 
tions. Let us inquire into the significance of the fact that it is so 
frequently engrafted upon the scrofulous dyscrasia. 

In the lecture upon hsematogenesis, or blood-making, which you 
heard only last evening, my colleague, the professor of physiology, 
directed your attention to the important function of the lymphatic 
glands, as related to that process. You were told that the chyle 
and lymph which are subjected to the action of these glands, are 
so changed thereby as afterwards to constitute a most essential 
part of the blood. The mesenteric glands manipulate the chylif- 
erous fluid which is en route for the general circulation. Both the 
superficial and the deep-seated lymphatics are designed to absorb 
any surplus of serum that may have been poured out in excess of 
the needs of the different tissues. They are the original physio= 
logical economists. They stamp their impress upon this fluid, and 
then pass it along into the blood-current again. This is the func- 
tion of lymphosis. As indicated in the lecture to which I have 
just referred, it concerns the assimilation of the oleo-albuminous 
element of the food. It is the first step in the process of histo- 
genesis or tissue-making. If this step is not properly taken, the 
blood becomes impaired in quality, and all the functions are likely 
to be implicated. 

Now this physiological knowledge is of practical application to 
the case before us. Scrofulous persons are unhealthy because this 
glandular system is predisposed to disease. Inflammation, or any 
of its consequences, may so impair the function of the lymphatics 
as to impoverish the blood, and even to render it harmful to the 
life-processes. Under these circumstances the albuminous princi- 
ple is not available for the repair of the tissues. It circulates as 
a foreign element, which must, in some way, be eliminated and 
expelled from the organism. It may find an outlet through the 
kidneys, or some other excretory apparatus ; but in escaping is 
very likely to develop a catarrhal inflammation of one or another 
of the mucous membranes. The mucous secretions are changed 
in amount and quality. They become the vehicle for carrying off 
those very elements which are needed in nutrition, but which have 
been rejected because the initiatory step in the process of their 
assimilation was not properly taken. In political parlance, there 
is so much " red-tapeism," so much respect for method and prece- 



ON THE DISEASES OF WOMEN. 43 

dent, in the affairs of our bodily organization, that the other organs 
and textures will neither recognize nor appropriate this class of 
proximate principles, unless they have been identified and stamped, 
or acted upon beforehand. 

The same is true of those glands which are set apart for the 
elaboration of their particular products from elements contained 
in the blood. It is quite as impossible for the gastric glands to 
secrete the proper solvent for the food from blood, the quality of 
which has been impaired in the manner just indicated, as for the 
muscular and serous, or other tissues, to repair themselves out of 
a like material. The mammary glands do not form an exception 
to this rule. This woman's milk is impoverished and injurious to 
the child, because in the blood which was brought to them the 
breasts failed to find the materials out of which they could manu- 
facture a wholesome product. Those elements were drained away 
in the critical discharge from the glands and follicles of the vagina 
and of the uterine cervix. 

Moreover, in consequence of the mammary glands having become 
eliminative, as well as secretory, it is not impossible that some of 

these abnormal elements may also escape with 
leuioTrh^Imthe mother" 1 tne mn ^ from the breasts. Such a product 

would be both non-assimilable and noxious. 
The infant would become impoverished and poisoned from nurs- 
ing it. It could not thrive upon such aliment. Hence the vom- 
iting, indigestion and diarrhoea which have resulted in the case of 
this woman's child. The rapid improvement in its health from 
changing its diet to good cow's milk confirms the view we have 
taken. 

In rare cases it sometimes happens that the nursing child 
becomes diseased in consequence of the mother's milk having 

been poisoned, through the absorption of drugs 
chlid dIrectpoisoningofthe that nave been injected into the vagina for the 

purpose of arresting a leucorrhceal flow. I am 
quite confident that I have seen more than one such infant in 
great suffering, and ill with an obscure disease, which was prop- 
erly chargeable to the acetate of lead, alum, tannin, etc., that had 
been used in the manner indicated. 

Reserving the differential diagnosis of uterine from vaginal leu- 
corrhoea for another lecture, I will call your attention to the sig- 



44 LECTURES, CLINICAL AND DIDACTIC, 

nificance of one or two objective symptoms presented in the case 
now under consideration. If this patient's flow, 
steYnitt 6 leucorrhoea and which is sometimes profuse, and has continued 
for two years, came from the uterine cervix, 
in all probability she would have remained sterile ; for, as I 
shall doubtless have occasion to show you, this form of leucorrhoea 
is a frequent cause of barrenness. And, besides, had it been uter- 
ine, and not vaginal, there would surely have been a partial or 
complete arrest thereof during pregnancy. Sometimes, however, 
both varieties may exist conjointly, or they may even alternate in 
the same patient. 

Treatment. — In all cases of leucorrhoea which are incident to 
gestation and lactation, you should bear in mind that the blood is 
being drained of its assimilable material for the growth of the 
offspring. For this reason it is sometimes quite impossible to cure 
the affection radically until these functions have ceased by limita- 
tion. In either case, indeed, the leucorrhoea may be critical, and 
it might therefore be injurious either to mother or child to arrest 
it while these processes are going on. This is a forcible argument 
against the use of astringents which are designed to seal up this 
flow, and to close a species of safety-valve to the general econonrv. 

There are two reasons that may justify, and even necessitate, 

the weaning of the child for the cure of a leucorrhoea which is 

incident to the nursing period. If the draught 

Weaning the child. , & 

upon the mother s resources while nursing, 
undermines her strength, it furnishes a cause for this disease 
which is constant in its operation, and which can only be removed 
by putting the child away from the breast. And weaning is still 
more strongly indicated if the child was large and plump at its 
birth, and the leucorrhoea continued during pregnancy also. Be- 
sides, the safety and welfare of the infant may require that it 
shall be brought up artificially, rather than upon the unhealthy 
milk that is furnished by the mother. 

Not unfrequently the cure is half performed when you have 
prevented a waste which only weakens the mother and injures 
the child. Stop the leak, and her strength may soon return. 
For it is a condition of healthy glandular activity, that the blood 
must be nourishing and stimulating to the glands as well as to 
other bodily organs. 



ON THE DISEASES OF WOMEN. 45 

It is no less important to select a suitable diet for this patient, 
than to decide upon the appropriate remedy for the symptoms 
presented. Indeed, the rational method of pro- 
cedure would be, first, to supply the physio- 
logical conditions that are requisite to health, in order that our 
curative agents may afterwards act more promptly and efficiently. 
Granted that, in the case before us, the function of the mesenteric 
glands is so impaired that they fail to effect the proper changes in 
the peptones brought to them from the bowel. The indication is 
to choose such an aliment as by their aid may be assimilated. The 
whites of eggs, lean meat, sea-food, as oysters or other shell-fish, 
or good fresh milk, are more easily digested and disposed of, and 
also more nourishing, than a mixed diet largely composed of fatty 
substances, soups, and the like. It is quite as necessary to dis- 
criminate carefully in this class of diseases, and to allow only such 
food as will be kindly received and appropriated, as it is in the 
case of the infant, whose digestion is very weak, and whose ali- 
mentary system is easily deranged. Sometimes the vegetable acids 
are not only grateful, but really beneficial. The patient may eat 
grapes, oranges, tomatoes, or baked apples, or she may drink a 
mild wine, or an occasional glass of lemonade. Now and then the 
most excellent results are obtained from travel, partly because of 
the change of scene and surroundings, but also, as the phrase is, 
"from change of pasture." The same food, cooked differently, 
may be more acceptable to the stomach of an invalid, and less 
harmful in every way, than if she had remained at home and eaten 
it from the same clish and table as before. 

But let us inquire if there is any means whereby the important 

function of lymphosis may be stimulated and encouraged. The 

salts of potassa, soda, lime, alumina, baryta, 

Lymphatic stimulants. . . .. v 

iron, iodine, ammonia, phosphorus, and other 
earths and metals, are all more or less intimately related there- 
with. As prepared by the pharmaceutist, or in the form of 
mineral waters in the great laboratory of Nature, they have long 
been employed for the cure of all the principal disorders of nutri- 
tion. And the almost universal record of the good results so 
frequently obtained from them, leads us to conclude that empirical 
observation cannot have gone very far astray in this matter. The 
hint, at least, is significant. Clinical experience confirms their 



46 LECTURES, CLINICAL AND DIDACTIC, 

value in the treatment of leucorrhoea. A majority of the reliable 
remedies for this disease are of mineral origin. And each of 
them has a specific, pathogenetic, and curative relation to the 
lymphatic glands. It is for this reason, doubtless, that they are 
most serviceable in the treatment of scrofulous and catarrhal affec- 
tions of almost every kind. 

Although these clinical generalities are both analytical and 
suggestive, they should not be allowed to substitute a more care- 
ful selection of the appropriate remedy or remedies. "We must 
choose from among all those named, and many more beside, the 
proper simillimum for the more prominent symptoms complained 
of. If you will turn to the pathogenesis of calcarea carbonica 
you will find it. The indications for this most excellent remedy 
are so positive and almost mathematically exact, that we need 
look no further. It is called for by the milky leucorrhoea, with 
aching in the vagina, and itching in the pudenda, with increased 
flow after exercise, and also in the case of a woman who is subject 
to a too copious and oft-recurring menstruation. 

In prescribing the calcarea carbonica in similar cases, and in- 
deed ordinarily, my own preference is for the third decimal tritu- 
ration. And, while I do not question the efficacy of the medium 
and higher preparations thereof, my experience is certainly opposed 
to the theory which holds that no curative effect can be obtained 
from this remedy unless it be given in the sixth or a higher 

potency. Mrs. will take one-and-a-half grains of the third 

trituration of the calcarea morning and evening, and report at the 
end of a week. 

TOO FREQUENT MENSTRUATION IN INCIPIENT PHTHISIS. 

Case. — Mrs. S., aged 32, residing in an adjacent state, gives 
the following history of her case. She has three children, the 
youngest of which is four years old. She nursed the latter for a 
period of twenty months, her menses appearing but twice mean- 
while. For two years past she has menstruated as often as once 
in three weeks, and sometimes every two weeks. Originally, 
menstruation was regular, and normal in all respects. With a 
single exception, which occurred about four months ago, the 
menses have not been very profuse. Eight months ago she lost 
her voice, and in all this interval has not been able to speak aloud. 
She has no habitual cough or sore throat, but is subject to occa- 



ON THE DISEASES OF "WOMEN. 47 

sional attacks of diarrhoea, which is very debilitating, and some- 
times quite intractable. Has never had the aphonia before, 
neither was she subject to the croup, or to any anginose affection 
during infancy and childhood ; is losing flesh rapidly ; appetite 
capricious; perspires freely whenever she sleeps; no thirst; 
pulse one hundred and ten. Tuberculosis is hereditary in the 
family. 

The relation of the menstrual function to the development of 

hereditary tuberculosis is more significant than you may have 

supposed. The interval between puberty and 

cu^oSf ruation and tuber " tlie a S e of tnir ty or thirty-five represents the 
period at which females are most liable to be 
seized with symptoms of that formidable disease. After this 
period, if the -menses are regular, they generally escape until the 
great climacteric is passed. The first ten years of menstrual life 
show the largest proportion of cases and the highest rate of mor- 
tality from phthisis pulmonalis. It is not uncommon for this 
disease to appear in young girls at the time the catamenial func- 
tion is established. Retention of the menses is very often a pre- 
monitory symptom. We shall, doubtless, have occasion to confirm 
its clinical import. 

But it sometimes happens, that too frequent menstruation may 
take the place of an arrest or tardy appearance of this flow in 
incipient phthisis. The case before us is one of this kind. For 
fifteen years, or from the age of fifteen to thirty, this poor 
woman menstruated regularly. Lactation was prolonged to twenty 
months, the menses appearing only twice before her babe was 
weaned. For the four months following, everything was normal 
in this respect. The courses then became too frequent, and have 
so continued until the present time. 

Healthy menstruation depends upon ovulation — the ripening 
and discharge of the ovum, which takes place every lunar month. 
It is possible that the physiological condition 
cu£s.° rrhagia and tuber " °f tnis peculiar flow may be supplied in excep- 
tional cases of too frequent menstruation. But 
in young subjects especially, clinical experience leads us to refer 
this remittent type of menstruation, as it has been styled by Dr. 
Tilt, to some severe constitutional or local disease or dyserasia. 
Sometimes it is caused by uterine ulceration, which maybe either 
benign or malignant. More frequently it is not organic, but origi-/ 



48 LECTURES, CLINICAL AND DLDACTIC, 

nates in the depraved and debilitated conditions of the system 
that are incident to phthisis pulmonalis, and to chronic diseases 
of various kinds. When it occurs so frequently, it loses the 
character of the catamenia proper, and becomes a passive haemor- 
rhage. Under these circumstances the condition of the blood is 
such that it very readily escapes from the uterine mucous mem- 
brane, which is more than ordinarily congested. Whatever im- 
pairs the quality of the blood, may thus directly give rise to a too 
copious, as well as too frequently recurring menstrual flow. 
Hence it is that instead of amenorrhcea in the early stage of 
phthisis, we sometimes meet with cases of troublesome and even 
dangerous menorrhagia. Indeed my own experience leads me to 
conclude that uterine haemorrhage, active or passive, is more fre- 
quent in women under thirty -five years of age, and who are pre- 
disposed to tuberculosis, than our authors and practitioners have 
generally imagined. As a rule, however, it is more liable to occur 
in advanced stages of the disease than in its incipiency, and in 
child-bearing women than in those who are either unmarried or 
sterile. 

In either sex indiscriminately it is not unusual for phthisis to 
commence with laryngitis, and consequent aphonia. But the 
marked sympathy existing between the womb. 
aph?n;a ficance ° f the the ovaries, and the larynx, renders this com- 
plication more frequent among females than 
with males. The loss of voice in this case is significant and seri- 
ous. If it were hysterical, it would not have persisted so many 
months. In aphonia from spinal irritation, (unless it be trau- 
matic), the attack comes on abruptly, continues for a few days or 
a week at most, and is very apt to leave as it came. Emotional 
causes, menstrual or sexual excitement, or bodily fatigue, may 
induce either of these varieties of aphonia. The loss of voice 
that sometimes precedes an apopletic fit depends upon congestion 
of the medulla oblongata about the ganglion of the pneumo-gastric 
nerve, and is a very different affair. The obstinate aphonia, the 
habitual diarrhoea, the menstrual irregularity, and the frequent 
pulse of this patient, are objective signs, which must be inter- 
preted as premonitory of pulmonary tuberculosis. 

Treatment.- — The remedy for this case is calcarea phosphorica; 
and you will be surprised to observe how promptly and efficiently 



ON THE DISEASES OF WOMEN. 49 

it sometimes acts under similar conditions to those presented by 
this patient. It may be given in the third, the sixth, or if you 
please, a higher potency. My own preference is for the third 
decimal trituration, of which this woman will take two grains 
three times daily. 

Not unfrequently the bichromate of potassa, phosphorus, 
sodium, or spongia, will relieve the hoarseness which is incident 
to these cases of incipient phthisis. For this purpose they may 
be given incidentally, or if otherwise indicated, in lieu of the 
calcarea phosphorica. 

It is quite as important to prescribe the proper hygienic condi- 
tions suited to this infirmity as it is to determine the choice of the 
remedy. First and foremost this patient should, 

Season and climate. .- . . 

it possible, remove to a climate which is less 
humid than this upon the lake shore. This expedient is especi- 
ally advisable at this season (February). For the weather of the 
late winter and early spring months in this vicinity is too change- 
able, and withal too damp, for persons who are predisposed to 
laryngeal and pulmonary difficulties. 

She should, moreover, have a good diet, and plenty of fresh air, 
without fatigue. And what is still more important, she should 

avoid an excess of family care and worry. Any 

Mental worry. tip n pit • i • 

little fret or friction of the domestic machinery 
has a wonderful influence in keeping this class of patients always 
on the doctor's hands. 

BURROWING ABSCESS OF THE MAMMARY GLAND WITH A SINUS. 

Case.- — Mrs. , aged 28, has two children, the youngest of 

which is three months old. She complains of a " gathered breast," 
which began to trouble her seven weeks ago, or when the babe 
was five weeks old. She first noticed what appeared to be a small 
*' cat-boil " on the right breast, which was not very painful and 
did not in the least interfere with nursing. It, however, contin- 
ued gradually to increase in size, and to become more tender. 
Three weeks ago her physician advised that it should be poulticed 
and afterwards freely lanced. The former part of the prescription 
was tried, but she would not consent to its being opened. As a 
consequence, the abscess broke at the end of another week, and 
although it seemed but a small affair, discharged a large quantity 
of healthy pus. The orifice through which this fluid escaped has 

4 



50 LECTURES, CLINICAL, AND DIDACTIC, 

continued to enlarge until it is now about the size of the nail of 
my index finger, and, only yesterday, she was startled by discov- 
ering that whenever the child nurses, or she swallows anything, 
and sometimes when she moves the right arm, the milk escapes 
quite freely from it. Two days since, another " boil " made its 
appearance at the lower and outer margin of the same breast, and 
now, you see the hardened, smooth, glossy and convex outline of 
the surface at that point, as the redness, and also the pain of 
which she complains, indicate that the suppurative progress is still 
going on. She is weak and feeble, with slight hectic, unrest, 
anorexia, and is withal very much discouraged. 

Unless it be located in the loose cellular tissue about the nipple, 
the mammary abscess which points like a boil is apt to be a serious 
and deep-seated one. This is especially true if the local and con- 
stitutional symptoms indicate that the gland has been inflamed for 
a considerable time. Under these circumstances, pus may form 
and collect at the base of the breast, or in the areolar structure 
that separates the lobules, long before there is any external sign 
preparatory to its escape. The size of the abscess proper is, there- 
fore, no criterion of its extent or gravity. Boils situated about 
the margin of the breast, and especially at its lower border, not 
unfrequently give vent to the contents of a burrowing abscess 
which may have existed for some weeks, and committed great 
havoc with the gland itself. There may be only one of these, but 
usually there are two or more which ripen successively. 

We occasionally meet with superficial abscesses that only involve 
the integument covering the gland, but these are not necessarily, 
or indeed frequently, seen in nursing women. They occur in young 
girls, in consequence of tight lacing, the wearing of hard and un- 
yielding pads over the breasts, or of bruising those organs in some 
accidental way, and scarcely deserve the name of abscess. 

The form of milk abscesses of which this is an excellent illus- 
tration, is peculiar to depraved conditions of system which consti- 
tute a species of cachexia. They are very prone to become sinu- 
ous, and the canals which are formed may be either superficial or 
deep-seated, running through or beneath the gland in every direc- 
tion. Multiple abscesses may communicate in this manner. 
Unless relieved by proper means, these sinuses may even become 
fistulous. It has happened that the entire mammary gland has 
been destroyed and discharged through these openings. 



ON THE DISEASES OF WOMEN. 51 

In the case under review, the extravasation and escape of milk 
is caused by a rupture of one or more of the proper lactiferous 
ducts, whieh are compressed during suckling, deglutition, and also 
when the arm is moved. It is hardly necessary to remind you that 
these symptoms require immediate relief, else they may persist 
and increase in severity until they destroy the patient's life. 

Treatment. — I have more confidence in phosphorus and silicea 
than in any other remedies for sinuous and fistulous abscesses of 
the mammary gland. It is best to give them separately. Perhaps 
you will succeed more frequently with the former than with the 
latter. They should be given in the sixth, or a higher potency, 
and the dose repeated every three to six hours. It has been claimed 
that the local application of the tincture of phoshorus in tepid or 
cool water is very serviceable also. The phosphorated oil of the 
shops will sometimes answer an excellent purpose as an external 
application. 

My practice has been, in most cases of this kind, to resort to the 
topical use of granulated sugar, which is a simple and unobjection- 
able domestic remedy. Applied directly to the 

A domestic expedient. ^ . 1 . 

surface ot the ulcer at the mouth of the sinus, 
whence the pus or milk, or both these escape, it stimulates fresh, 
healthy granulations, and closes the unnatural outlet. It oper- 
ates kindly and speedily, is a good antiseptic, and is always avail- 
able. It may be insinuated into the canal without doing any pos- 
sible harm, or causing severe pam. 

If this simple expedient fails, you may inject a weak solution 
of tincture of calendula into the sinus by means of a clean ureth- 
ral syringe. And the same solution may also be applied over the 
ulcer at the site of the abscess. Calendula is sometimes wonder- 
fully efficacious where there is considerable loss of the integu- 
ment, and where an extravagant quantity of pus is formed. 

The old plan of slitting up these sinuses with a knife was cruel, 
barbarous and unnecessary. It is undoubtedly true that, in a 

maioritv of cases, these deep-seated abscesses 

The knife. #. i ii-iii 

once formed would seldom become sinuous and 
fistulous if they were promptly and properly opened, but this fault 
does not justify the subsequent slashing and hacking of these 
delicate organs. There is a proper time for all things, including 
the lancet. And the same is true of the caustic and astringent 



52 LECTURES, CLINICAL AND DIDACTIC, 

injections which have been thrown into these passages here- 
tofore. 

As in other abscesses that involve a considerable drain upon the 
patient's strength, we must counteract the loss and fortify against 
it. This woman should have a good, nourish- 
ing diet of eggs and lean meat. Beef is prefer- 
able, and may generally be taken in the solid form. Of all vege- 
table substances which are appropriate to cases of this kind, oat- 
meal is best. Bread made from unbolted wheat flour, --thus 
securing the phosphorus which is contained in the hull of the 
grain, — is also advisable. According to Agassiz's theory con- 
cerning the large relative proportion of the same element in fish, 
we may sometimes select from this class of food. The fish should 
also be lean. Fresh air and sunlight, with freedom of the mind 
from all harassing cares, are excellent and available tonics. 

Mrs. will take of phosphorus 6th, a dose every four hours 

during the day. The granulated sugar to be applied twice daily. 
The diet to consist of brown bread and butter, and rare roast 
beef, with dry, mealy potatoes. She must nurse her babe from 
the left breast exclusively.' The right one should, however, be 
well drawn by means of a breast-pump each morning and even- 
ing, and then kept soft and warm. Let her report at the end of a 
week. 

ABORTION WITH MISPLACED PAINS. 

Case. — In consequence of over-exertion, Mrs. G., aged 30, 
aborted at the end of the third month. She had twice before mis- 
carried at the same period of pregnancy. Immediately after vio- 
lent exercise at house-cleaning, she began to flow slightly, and to 
experience an occasional sharp pain in the left hypogastrium. After 
a restless night she awakened at 6 A. M. with an acute, lancinating 
headache. This pain in the head was accompanied by an extreme 
soreness and tenderness in the nape of the neck. The pupils were 
dilated to nearly the whole extent of the iris. She complained of 
photophobia, with a shower of sparks before the eyes, and in a 
species of semi-delirium declared herself in the immediate neigh- 
borhood of a fearful conflagration. These latter symptoms would 
disappear in the intervals between the paroxysms of headache. 
When the pain in the head returned, she would scream and shriek 
and beg to be held firmly, in order that no terrible accident might 
befall her. These paroxysms returned every ten minutes for about 



ON THE DISEASES OF WOMEN. 53 

two hours, or until I came and relieved her with a few doses of 
belladonna 3rd. Upon examination, the os uteri was found but 
slightly dilated. The pain subsided, and finally ceased. 

The same train of symptoms came on the second morning at six 
o'clock. They were, however, less violent in degree and of 
shorter duration, lasting in all not more than an hour. The os 
uteri was a little more patulous. The passive flow continued, but 
there were no uterine pains whatever. 

The third morning she had half a dozen of the same paroxysms 
of pain in the head. They were repeated once in five or six min- 
utes, and were as severe as those of the first day. In the intervals 
she was found to be bleeding much more freely. 

The stomach had become exceedingly irritable, and she vomited 
frequently, each effort at emesis serving so perceptibly to increase 
the haemorrhage that the patient remarked it herself. The head- 
ache passed off, but during the day she had two pretty severe 
uterine pains of an expulsive character, and became really quite 
ill. Early next morning regular labor pains commenced and con- 
tinued, so that in an hour and a half all was over. The head and 
nervous symptoms vanished as soon as the proper uterine contrac- 
tions began. The fifth morning the headache did not return. She 
made a good recovery. 

Perhaps a majority of cases of accidental abortion are caused 
by undue or unusual muscular exertion. Lifting, scrubbing, over- 
reaching — as in hanging a picture, carrying a 
erdo b n°. rti ° n fr ° m over ' ex * child a long distance hurriedly — as when in 
haste to reach home or to take the train, run- 
ning the sewing machine for consecutive hours and days, horse- 
back riding, or climbing steep and difficult stairs, as, for example, 
to the cupola of the city hall, have caused the uterus to expel its 
contents prematurely. • 

You will not, however, understand me to say that these causes 
are invariably followed by such unfortunate consequences. Far 
from it. In many, and probably most pregnant 
ex?rc^e" kable tolerance of women, there is a remarkable tolerance of 
fatigue and even considerable muscular effort, 
if it be moderately and habitually practised. There are those in 
whom it would be impossible to bring on abortion by any such 
means. But in the majority of cases such a mishap is more easily 
induced. This is especially true of women of sedentary habits, 
who ordinarily take very little exercise, whether indoors or out, 
but who, under peculiar temptation, or provocation, exceed the 



54 LECTURES CLINICAL AND DIDACTIC, 

bounds of prudence, and overdo and injure themselves. In the 
matter of taking proper exercise, as in everything they do, these 
subjects are fitful and capricious. In them a sudden strain, or any 
unusual effort, conjoined with extraordinary nervous excitement 
and impulse, may work mischief that might have been averted. 

Add to this that, if the woman has aborted once or twice 

already, and is, therefore, predisposed to this accident, these 

causes are more harmful, and we have the eti- 

The "habit" of aborting. . 

ology oi this class ot cases plainly beiore us. 
The habit of aborting at a particular date of pregnancy also 
increases the danger from this variety of accidental causes ; for 
there are women who miscarry at a certain time with almost as 
much regularity as they menstruate when they are well. And, 
although this result may happen at any period of gestation, it is 
extremely liable to occur at the end of the third month. This 
clinical fact is confirmed in the case just now detailed to you. 
Our patient had already miscarried twice at the twelfth week, 
and now, with the arrival of the same period, over-exertion in 
house-cleaning caused a slight uterine flow and pains, which 
resulted in the loss of the embryo. You should not fail to recog- 
nize chat this indiscretion and excess on her part were more mis- 
chievous at this particular time than they might have been at any 
other. 

Even a slight flow of blood from the gravid uterus, and espe- 
cially if it be accompanied by pain in either hypogastrium, or 
about the loins, may betoken a miscarriage. Under these circum- 
stances the symptoms of impending abortion do not differ, in any 
essential particular, from those which date the appearance of the 
menstrual discharge. We are naturally suspicious of them, how- 
ever, and solicitous concerning their interpretation and results; 
for their continuance signifies an interruption in the process of 
intra-uterine development, and the possible sacrifice of offspring. 

But the chief peculiarity of this case was the periodical and 
regularly recurring headache. This was a good example of inter- 
mittent abortion.* The headache took the place 

Intermittent abortion. *■ 

of the uterine pains, came every morning for 
three successive days, continued for a given time, and then left. 

*Vide U. S. Medical and Surgical Journal, vol. iv., p. 75. 



ON THE DISEASES OF WOMEN. 55 

The paroxysms, which were distinctly pronounced, came and went 
with the regularity of labor pains. And they increased in fre- 
quency each day. Meanwhile there was no expulsive uterine 
effort, or at least none of a painful or positive character. By and 
by the flow increased, and the stomach became implicated. Vom- 
iting ensued. This was a certain sign that the os uteri had begun 
to dilate more freely and rapidly. The principal obstacle to deliv- 
ery, and the indirect cause of the headache also, were removed as 
soon as the cervix was sufficiently relaxed for the escape of the 
contained embryo. Proper uterine contractions succeeded. The 
real labor was short and decisive. The headache vanished, haem- 
orrhage ceased, and our patient made a good recovery. 

Treatment. — There are several methods by which this case 
could have been brought to a successful termination. The ques- 
tion to decide was, which is the more safe and expedient. I might 
have given this woman a strong dose of ergot, and finished her 
labor abruptly, by forcing the uterus to expel its contents through 
the slowly dilating os. Or, perhaps, a powerful cathartic would 
have produced a similar result. Or an emetic might have unlocked 
the cervix, with the mysterious key of reflex action. Or sitz-baths, 
or the colpeurynter, might have brought about the same end. Or 
an old-fashioned dose of morphine, or perhaps of quinine, might 
have arrested the headache until such time as the gradual expan- 
sion of the lower segment of the womb should permit the proper 
pains to come on spontaneously, and terminate the delivery. 

But the belladonna was a more appropriate, specific, and satis- 
factory remedy. Not only did it relieve the headache, which, as 
I have said, was indirectly due to the rigidity of the uterine neck, 
but it also relaxed the fibres of the unyielding cervix — which is 
slow to yield before the fourth month — and thus removed the 
cause of the suffering and the delay. It was appropriate for the 
pain in the head, because it was specifically adapted to remedy 
the condition of the cervix, upon which it depended, and of which 
it was the consequence. It harmonized the nervous sympathies 
existing between the body of the womb and its inflexible outlet. 
It charmed away the impending danger to the brain, and permit- 
ted nature to complete the delivery with the least possible risk to 
the health and welfare of the patient. 



56 LECTURES, CLINICAL AND DIDACTIC, 



LECTURE III 



amenorrhea with hysterical spasms resembling chorea- 

Gentlemen : 

No class of diseases to which women are subject is more inter- 
esting and important than the disorders of menstruation. They 
are more frequently encountered, are more intricate and enigmat- 
ical, and, all in all, more difficult of cure than any others. Here 
is a case belonging to this class, which is certain to attract your 
attention because of some unusual incidental symptoms. 

Case. — Miss , aged 19, of full habit and general good 

health ; is almost never ill. Her mother saj^s that four days ago, 
on Sunday last, she took cold while in attendance upon the Mission 
Sabbath School. In consequence of this her menses were arrested, 
and the same evening she was seized with a severe headache, which 
has continued with abated violence day and night until the present 
time. This pain is described as acute at intervals, extending over 
the whole head, and aggravated by noise and light. The pupils 
are slightly dilated, and the face occasionally flushed. She sees 
objects distinctly, and is rational all the while. Since the onset of 
the attack, however, she has not been able to sleep more than a 
very few minutes at a time. Two hours ago a new train of symp- 
toms was developed. These symptoms have alarmed the parents 
and friends exceedingly, and for their explanation and cure we have 
been consulted. Her relatives are in great dread of paralysis. 

The right hand and arm commenced to jerk spasmodically, so 
much so that at times it became quite unmanageable. Sometimes 
the arm and forearm were thrown about wildly, and then extended 
and flexed quickly and violently. Again, the muscles of the shoul- 
der were so severely convulsed as to threaten the dislocation of the 
head of the humerus from the glenoid cavity of the scapula. Occa- 
sionally, during these paroxysms, the shoulder is thrown high up 
alongside of the head. These movements are involuntary. It is 
quite impossible for the patient to control or suppress them, and 
when they have ceased temporarily she complains of great fatigue 
in the affected arm and shoulder. The paroxysms recur as often 
as once in five minutes, and, as you will observe, are somewhat 



ON THE DISEASES OF WOMEN. 57 

grotesque as well as painful to behold. Excepting the left arm, 
which is but slightly affected, the remaining portions of the body 
and extremities are not implicated. The pulse is only 80, and nor- 
mal in every respect. She urinates freely and frequently, but the 
catamenia have ceased entirely since Sunday. She thinks that when 
the nervous twitching and spasm commenced in the arms and shoul- 
ders the headache became less severe in degree than it was before. 

It often happens that the menstrual flow is suddenly checked 
by " taking cold." Getting the feet wet, exposure from insuffi- 
cient clothing, or from sitting in a draught of air, may induce a 
complete arrest of the discharge. In the case before us this result 
was produced by some such apparently trivial means. 

Practically speaking, there is a distinction between suppression 
and retention of the menses, which you should never forget. Sup- 
pression of this function implies its complete 
Difference between sup- arres t or rather, that the ovaries and the uterine 

pression and retention. ' ' u 

mucous membrane have failed to furnish the 
products which constitute the true menstrual secretion. Retention 
of the menses signifies that, although the catamenial fluid has been 
secreted into the cavity of the womb, yet, for some especial 
reason, or reasons, its escape has been prevented. In the one 
case it is not poured into the uterus ; in the other it is not poured 
out of it through the vagina. This distinction corresponds with 
that made between urinary suppression and retention. In the 
former, the urine is not secreted, its elements are not selected by 
the renal organs from the blood which is brought to them. In 
the latter, although the kidneys have done their work, the ureters, 
the bladder, or the urethra, are in a condition which obstructs the 
flow and prevents the discharge of their proper product. 

A sudden arrest of the menses, " while the flow is on," is likely 
to re-act either upon the circulatory or the nervous system, or 
upon both together. This is a fruitful source 
arSstTfmerfs e e a s! e from of ill health among women. While this func- 
tion is being performed, it is the easiest thing 
imaginable, by such means, to convert a physiological injection of 
the ovaries, and of the uterine mucous membrane, into a patho- 
logical state of congestion and inflammation. This is a short step, 
and it is taken in a twinklings The most serious and intractable 
results may follow. Other and remote organs with which the 



58 LECTURES, CLINICAL AND DIDACTIC, 

pelvic viscera are in sympathy, may be implicated. Here we have 
evident determination of the blood to the brain, which is directly 
attributable to this cause. Sometimes this result is even more 
pronounced and alarming. There are those in whom the slight- 
est and most temporary arrest of the menstrual flow will induce 
cerebral lesions that threaten to destroy both reason and life. 
Our patient has suffered extremely from symptoms of this kind. 
Fortunately she has escaped the delirium which is usually present 
in such cases. In its stead, however, there is the insomnia which 
implies great nervous perturbation and derangement. 

The spasmodic phenomena have followed indirectly. They are 
symptomatic. In their production it is probable that the cere- 
bellum has been especially implicated. For, 
ph S enS°nT atic nervous according to Flourens, Dalton and others, it is 
the particular function of that part of the brain 
to preside over and co-ordinate, or harmonize the voluntary mus- 
cular movements. In these choreic jerkings we have evidence 
that this function is disordered. This young lady suffers from 
what has been improperly styled " insanity of the muscles." The 
muscles of the right shoulder and arm are in a state of insubor- 
dination to the will. She commands, but cannot control them. 
Their irregular and forcible action is exhaustive, and it is not 
strange that a temporary arrest of the spasms is accompanied by a 
sense of weariness of the affected parts. Excepting from extreme 
exhaustion, there is no danger of her becoming paralyzed. 

If, instead of the cerebellum, the cerebral lobes were involved 
in this case, there would have been marked delirium, and perhaps 
a mild and self-limited form of mania. Cerebral troubles, depend- 
ent on sudden interruption and arrest of the menses, are apt to be 
characterized by wakefulness, and oftentimes by utter inability to 
sleep. The hysterical peculiarities which this case presents are 
also due to the menstrual complication. 

Treatment. — The choice of remedies for the symptoms just 
detailed and analyzed is between belladonna and gelseminum. I 
prefer the former, because it corresponds more nearly to the 
patient's habit and temperament ; to the probable cause of the 
menstrual suppression ; to the brain symptoms dependent on the 
same, in all their minuteness ; and to the reflex spasms of the vol- 
untary muscles of the shoulder and arm. It is better adapted to 



ON THE DISEASES OF WOMEN. 59 

the congestive tendency dependent on the arrest of the catame- 
nial flow than any other remedy. If this patient had been seized 
immediately with the spasms ; if the choreic symptoms had devel- 
oped the moment the menses ceased, we would have ordered the 
gelseminum. For, in that case, the suppression would have de- 
pended on a sudden contraction of the cervix, analogous to that 
which sometimes takes place in labor. And the gelseminum is 
even better fitted to overcome that contraction than the bella- 
donna. But here the nervous symptoms were preceded by an evi- 
dent afflux of blood to the brain. This was the primary lesion, 
and the order of sequence is a significant factor in the choice of a 
remedy for any given class of symptoms. Belladonna not only 
corresponds with the cerebral lesion, but is equally applicable to 
the relief of the muscular symptoms arising from it. 

Precisely what degree of importance should attach to a restora- 
tion of the menses in these cases, it is sometimes difficult to deter- 
mine. The old method was to force their 
should the flow be forced re t-Qrn by the use of emmena2[0£:ues, cathartics, 

to return ? «/ o o > 

hot herb teas, and the warm bath. And this 
under the impression that the symptoms which had their origin 
in the arrest of the flow could not be so promptly or effectually 
relieved as by its re-establishment. In many cases, where they 
were resorted to at once, and if they were not too powerful, these 
means were, no doubt, efficacious. Patients were cured in what 
was called a common-sense sort of way. But where, as in the 
case before you, a considerable time has intervened between the 
cessation of the proper menstrual flow and the making of the pre- 
scription, it is certainly prejudicial to the health and welfare of 
the patient, indeed, unphysiological, to attempt to bring it on 
again. Relieve the indirect symptoms by direct remedies, as 
speedily as possible, and trust to the natural powers to restore 
the function at or near the next " period." Where there is evi- 
dent determination of blood to the head, I can see no valid objec- 
tion to foot and hip baths as adjuncts to our remedies. 

This one thing you may bear in mind with respect to this form 

of amenorrhcea. When some exciting cause 
S uppre S s e s q ion nt troubIe from nas suppressed the discharge suddenly, and 

when, after a few hours, or days at the far- 
thest, the flow is not resumed, the chances of trouble at the next 



60 LECTURES, CLINICAL AND DIDACTIC, 

"period" will vary with the degree of congestion and inflammation 
of the uterus and ovaries consequent upon that suppression. If the 
mishap has reacted upon these organs exclusively, the mischief is 
likely to be perpetuated in the form of dysmenorrhcea, menorrhagia, 
permanent retention, sterility, etc. But if, on the other hand, the 
brain is involved, any subsequent irregularity of menstruation will 
not be so apt to follow. Symptomatic disorders of the nervous 
system, dependent on this variety of menstrual arrest, are self- 
limited, and seldom interfere very seriously with the resumption 
of the flow at the next and subsequent periods. The importance 
of this rule is shown in the treatment which it is proper to pursue 
under these varying circumstances. In the former case there is 
manifest need of treating the patient during the monthly interval, 
so as, if possible, to avert more serious consequences, and to 
secure the punctual appearance of the accustomed discharge. In 
the latter, the present symptoms should be relieved, and the gen- 
eral system regulated by attention to the diet, and by exercise in 
the open air, after which we may safely leave the rest to nature. 

I might spend the whole hour, most profitably, perhaps, in 

insisting upon the especial need of rest in this class of cases. 

When you visit such a patient,' you will very 

Rest and quiet. .. . 1 

likely find her in an illy-ventilated apart- 
ment, surrounded by a host of anxious relatives, including one or 
more lovers, and neighborhood gossips enough to discourage her 
or drive her crazy, and to consume the oxygen to which she alone 
is entitled. Your first duty, in such an extremity, will be to clear 
the room of its unwholesome contents. If these "friends" are 
adhesive and pertinacious, and you cannot devise any better expe- 
dient, you may quietly hint that these symptoms are very pecu- 
liar, and may possibly develop into some contagious affection, as, 
for example, the small-pox. This will have the effect to scatter 
those mischievous comforters, whose sympathy is a curse instead 
of a blessing, and you can then forbid their return. In similar 
nervous states the most trivial causes may perpetuate the diffi- 
culty. A noisy door-bell, a talkative nurse, too much light, or 
sound, or stir in the room, or house, the doctor's creaky boots, 
and many other things may counteract the influence of the 
most appropriate internal remedies. It is a very important part of 
your duty to recognize and remove all these obstacles to recovery. 



ON THE DISEASES OF WOMEN. 61 

The patient will take a dose of belladonna 3rd, once in three 
hours during the day, and we shall see how promptly and satisfac- 
torily she will recover.* 

ABDOMINAL CRAMPS AND PAINS IN PREGNANCY. 

Case. — Mrs. S is six and a half months advanced in her 

second pregnancy. For three weeks past she has complained of 
occasional pains and cramps in the abdomen. These sufferings 
are increased by exercise, slight pressure, emotional causes, and 
especially by the too vigorous movements of the foetus in utero. 
Upon examination I found the abdominal parietes somewhat atten- 
uated, and the uterus in the position of right lateral obliquity. 
Otherwise I discovered nothing abnormal. 

Unless the uterus is very decidedly displaced, abdominal and 
sacral pains, cramps in the limbs, and like symptoms, are not very 
apt to worry the pregnant woman prior to 
four r th m month CM after the quickening. After the fourth month, how- 
ever, and in exceptional cases as early as the 
third, they may be the cause of much suffering. They depend 
on the changes which the uterine and abdominal structures neces- 
sarily undergo in consequence of the development of the foetus. 
As you would naturally suppose, these symptoms are most fre- 
quently met with in primiparse — those who have never borne 
children before. Occasionally we find a patient who always 
experiences them during pregnancy. 

As the uterus enlarges, there is a gradual distention of the 
abdominal walls. A very natural consequence of this distention is 
the production of muscular and neuralgic pains. These pains, 
which are sometimes general, again local — as in certain forms of 
hysteria — sometimes shooting and cramp-like, and again more 
constant, are very likely to be referred to the points of attach- 
ment of the various muscles which comprise the parietes of the 
abdomen. They may be felt in either the right or the left liypo- 
chonclrium, in the iliac or umbilical region, and finally may settle 
into the permanent lumbar distress which in many cases precedes 
abortion. Not unfrequently, on account of its tension and 

* At the end of twenty-four hours the headache had ceased ; and at the end of the 
second day (the sixth from their commencement) the spasms left also. Three 'weeks 
later, at the usual time, the menses returned spontaneously. 



62 lectup.es, clinical and didactic, 

extreme tenderness, -when the belly lias become hard and full, the 
skin is the seat of the difficulty. In such a case there is a neu- 
ralgic affection of the cutaneous nerves, which is frequently mis- 
taken for inflammation of the womb and its appendages. 

In most cases like the one before you, and whatever its seat 
and character, the suffering is increased by motion. Any exercise 
which renders it necessary for the patient to 
SU fflrii° n increases the breathe more deeply and frequently than 
natural ; coughing or straining at stool ; riding 
or walking , turning in bed, or getting into an upright from a 
horizontal position ; the rolling of flatus in the bowels, or the move- 
ments of the foetus in utero ; may produce or aggravate it. It is 
usually worse when upon the feet than when sitting, and when 
sitting than when lying. There are, however, many exceptions to 
this rule. Excepting towards the end of pregnancy, say after the 
seventh month, it is generally worse in the day and better at night. 
It may be increased by mental emotions, as fright or anxiety ; and 
is more annoying and obstinate in those who are of sedentary habits 
than with the active and industrious. Lean women are more liable 
to it than the more robust. In rheumatic and neuralgic subjects it 
may depend upon vicissitudes of wind and weather for an excit- 
ing cause. Puny, nervous, and delicate children are more active 
and restless in utero, and therefore occasion more suffering of this 
kind, than those that are strong and vigorous. 

Diagnosis. — With respect to the prognosis and treatment, it is 
very important to be able to differentiate between the several 
varieties of abdominal pains to which pregnant women are subject. 
Among the lesions to which they are especially liable, we should 
separate the peritoneal from the neuralgic, the muscular from the 
uterine, and the ovarian from the intestinal. 

There is a spurious or false peritonitis, which rarely occurs 

except at the menstrual period, or at the time in the month which 

„ . . . . corresponds to it during gestation. It usually 

Spurious peritonitis. x ° ° ^ 

commences with a chill and local pain of an 
acute, lancinating character, in the region of one or both ovaries. 
The corresponding limb is flexed, and cannot be straightened 
without great increase of suffering. The affected part is exceed- 
ingly tender to the touch, and pressure, slight or severe, is insup- 
portable. This pain becomes gradually more diffuse. These 



ON THE DISEASES OF WOMEN. 63 

symptoms are accompanied by more or less fever and constitu- 
tional disturbance. 

In the cutaneous neuralgia, although the diagnosis is not diffi- 
cult, the most unpardonable blunders are frequently made. Tar- 
nier's remarks upon the subject are exceedingly 
neuraSr 1 ^ 101110111 ^ 60115 appropriate, and I quote them :* " Having for 
some time made a special study of these abdom- 
inal, inguinal, and lumbar pains, we are convinced that very 
often they are due to neuralgia of the cutaneous nerves from the 
collateral branches of the lumbar plexus. To be assured that 
such is the case, it is only necessary to test carefully the sensi- 
bility of the skin in these regions, either by rubbing it rudely 
with the end of a pencil, or by raising it in the form of a fold 
which is to be gradually pinched between the fingers. Pressure 
ought also to be made all along the crest of the ilium, in the 
direction of the genito-crural nerve. Should we be satisfied with 
merely questioning the patient, or depressing the walls of the 
abdomen by the hand, we would incur the risk of obtaining very 
little information, or of suspecting the existence of deep-seated 
visceral pain when the skin only is affected. This mistake, which 
we see committed every day, would be avoided by taking the 
trouble to make the above-mentioned examination, and we can- 
not recommend it too highly. The principal parts affected by this 
neuralgia are the lumbar, iliac, hypogastric, and inguinal points, 
though the pain may appear in some other portion, of greater or 
less extent, of the skin of the abdomen. Sometimes confined to 
a circumscribed point, it occasionally invades an entire half of 
the abdominal walls. It very rarely affects both sides at the same 
time with equal intensity." 

If the abdominal muscles are the seat of the suffering, the pains 

are cramp-like, and accompanied by knotting of the fibres, which 

is worse upon pressure or motion. The suffer- 

Characteristic symptoms. . „ _ 

ing between the severest paroxysms is referred 
to the points of origin and insertion of separate muscles. This 
form is most frequent in rheumatic subjects, in whom there may 
be a sudden metastasis to either of the larger articulations. It 
sometimes arises from traumatic injuries, as, for example, a blow 
or fall upon the abdomen. 

* Cazeau's Midwifery, Revised and Annotated by S. Tarnier. Phila. : 186S. p. 521. 



64 LECTURES, CLINICAL AND DIDACTIC, 

Metritis is a rare concomitant of gestation, but we not unfre- 
quently encounter a species of uterine colic that is apt to be mis- 
taken for one of the former affections. Hyster- 
ical women, who are highly emotional, and, I 
may add, exceedingly impulsive and imprudent also, are liable 
through some indiscretion, to attacks of this kind, and more 
especially about the period of quickening. So, also, are those 
who have been martyrs to dysmenorrhcea. The pain is referred 
to the uterine region and remains there. It may be intermit- 
tent, but it is not erratic like the muscular variety. It is prone 
to assume some of the characters of labor pains, and if long con- 
tinued or extreme in degree, may really precipitate a miscarriage. 
If we except their peritoneal envelope, the ovaries are singu- 
larly exempt from disease during pregnancy. From the date of 
conception their function is physiologically sus- 
diSas^ ption from ° varian pended and the condition which threatens their 
healthy action while menstruation continues is 
withdrawn. From various causes, however, their investing mem- 
brane may become inflamed, in which case the symptoms need 
not be confounded in your minds. The pain which is referred to 
the ovarian region, is sharp, and sometimes intense, or pressing, 
throbbing, burning, and paroxysmal. It may radiate over the 
abdomen, or extend into the back, or down the limb of the affect- 
ed side. This limb is generally flexed, or if the patient tries to 
walk, she is lame with it. In exceptional cases pregnant women 
are, however, liable to a form of ovarian neuralgia. 

The gastro-intestinal disorders incident to pregnancy are more 
annoying and frequent before the fourth and after the seventh 
month than between these two periods. When- 
de^Scilnu^giScy: ever the J occur > however, they are accompa- 
nied by such marked digestive derangement that 
you will have little trouble in their differential diagnosis. 

Prognosis. — I recommend you in no instance to regard a case 
of this kind as trivial. For there is not one of them which is alto- 
gether exempt from the liability to abortion and its fearful conse- 
quences. Throughout its whole course, the state of pregnancy is 
beset with contingencies which it is your duty to avert. And not 
the least serious among them are such as may develop from symp- 
toms like those of which our patient complains. 



ON THE DISEASES OF WOMEN. 65 

Treatment. — This is one of those cases which we often encount- 
er in private practice, and which are distinguished by this pecul- 
iarity — they are better managed by simple domestic expedients than 
by the most scientific prescriptions. Yet, as I have said, we must 
discriminate. For example : 

If the pains are muscular, the part may be bathed quite fre- 
quently with hamamelis. Perhaps as large a proportion as one- 
half of all the pregnant women who complain of these symptoms 
may be relieved by this means alone. It is equally appropriate in 
ovarian irritation and inflammation. In some cases the rhus toxi- 
codendron answers a good purpose. I generally direct a table- 
spoonful of the strong tincture to be put into a teacupful of tepid 
or cool water, and then applied through one or more layers of 
flannel. 

If the suffering has been caused by mechanical means, or is the 
result of injury, the tincture of arnica may be applied in the 
same manner. 

If it is caused by undue pressure against the attenuated walls 
of the abdomen, you may counteract this effect by enveloping the 
abdomen in several layers of an elastic bandage of rubber-cloth 
in such a manner as to support its parietes. A bandage of linen 
would be too unyielding, and might indirectly induce abortion. 

Toward the latter end of pregnancy the feeling of extreme dis- 
tention and discomfort in the abdomen, will often yield to the old 
and simple expedient of anointing it with sweet oil. I have seen 
the most threatening symptoms of premature labor relieved in 
this manner. If the pains are cramp-like, the camphorated oil is 
an excellent application. 

If the suffering is neuralgic, you will charm it away by direct- 
ing that the affected part be covered with simple, dry, uncarded 
cotton, or cotton batting. In some cases, several layers of flannel 
will answer equally well. Belladonna, or atropine, internally, 
may hasten the cure. 

In the ovarian neuralgia which sometimes complicates the symp- 
toms, and greatly increases the suffering in these cases, I know of 
no remedy to compare with the valerianate of zinc. I shall have 
more to say in future of this contingent of pregnancy. 

It is very important always to regulate the exercise of the 
patient, and as far as possible to prevent too much of mental fric- 
5 



66 LECTURES, CLINICAL AND DIDACTIC, 

tion and anxiety on her part ; for, although anatomists have failed 
to demonstrate a nervous connection between the mother and the 
foetus in utero, her mental emotions do influence it greatly. It is 
a bad habit for those who are pregnant to take care of, and to lift 
and carry around, other children in the family. Although tight- 
lacing is popularly believed to contribute to an easy and safe labor, 
it is often prejudicial to the comfort and welfare of the pregnant 
woman, by inducing abdominal pains and cramps which may result 
in abortion. 

Internally, a variety of remedies may be indicated. Where, as 
in this case, the suffering is aggravated by motion, however slight, 
bryonia will sometimes afford almost instant relief. Nux vomica, 
Pulsatilla, belladonna, rhus tox., ignatia, and chamomilla, are also 
useful under appropriate indications. This patient will take bry- 
onia 3d, three times daily. 

EXCESSIVE ABDOMINAL DEVELOPMENT IN PREGNANCY. 

It sometimes happens that symptoms which are analogous to 
those afforded by the patient who has just left the room, depend 
on other causes than those already named. Only yesterday I was 
consulted by letter in a case of this kind. My patient writes : 

Case. — I had called myself seven months advanced in preg- 
nancy, but many things conspire to make me think it probable 
that I am at least eight months along. I am exceedingly large, 
and from my extreme size, suffer greatly from faintness. For a 
fortnight I have endured severe pain in my left side, which noth- 
ing will relieve, although sitting up aggravates it. It has become 
almost unbearable, wearing my life and strength away, and giving 
me no rest, day or night. 

" My little ones have always been large, weighing ten or eleven 
pounds, and you know 1 am a wee bit of a woman. But now the 
doctor thinks it probable that there may be two of them, which 
are small, but amazingly strong and active, while there is evi- 
dently a great quantity of water contained in the womb. The 
child was in such a position as to cause much suffering and uneasi- 
ness, it being apparently across the pelvis. The doctor gave me 
Pulsatilla, and whether it produced the effect or not, one week 
later it was pronounced ' all right.' 

" Will you be so kind as to inform me if there is anything that 
will relieve this pain in my side ? If it should continue, would it 



ON THE DISEASES OF WOMEN. 67 

not be well to hasten delivery, before I am altogether worn out ? 
I frequently have severe and almost unbearable contractions, 
which cause the abdomen to feel as if turned into stone." 

This case presents several points of practical interest. As you 
will observe, it supplies additional details, and is an excellent 
appendix to the former one. Gestation is more advanced, and 
the symptoms are different. 

During pregnancy the size of the abdomen is relative. There 

is no actual scale of measurement or development for all, or even 

for single patients, who are successively preg- 

Size of the abdomen as a tt • ., . . „ 

sign and sequence of preg- nant. Hence the absolute impossibility of 

nancy. .... 

judging by this sign whether a woman is in the 
seventh or eighth month. The abdomen is proportionally larger 
in short than in tall women, in multiparse than in primiparse, in 
those who are pregnant with twins than in case the womb con- 
tains but a single foetus. Its prominence varies with the laxity 
of the abdominal walls, the position of the uterus, the size of the 
foetus, and possibly its position, and with the quantity of amniotic 
liquor that surrounds the child or children. It may also become 
very large from intestinal indigestion and tympanites, abdominal 
dropsy, uterine or ovarian tumors, and malformation or dropsy of 
the foetus. 

Whatever their cause, these symptoms give rise to suffering 
and apprehension. They convert a natural process into a species 
of martyrdom, which, luckily, is self-limited. 

Diagnosis, — You will sometimes find it extremely difficult, and. 
indeed, quite impossible, to determine the cause or causes of these 
symptoms and the lesions, functional and organic, of which they 
are the token. A pendulous belly, with undue size of the abdom- 
inal tumor, occurs more frequently in spare, ill-conditioned women 
than in those who are short, plump, and well nourished. The mus- 
cles are thin and flabby, and the patient is more or less anaemic. 

If the extraordinary size depends on the position of the uterus, 
that organ will be found to incline forwards, over the pubes, or to 
one or the other side of the abdomen — usually to the right side. 
If upon the size of the child, its outline can be felt through the 
abdominal walls. Note should also be taken of the size and 
weight of former children, if the patient has ever been pregnant 
before. The chances are that, having always had very large child- 



68 LECTURES, CLINICAL AND DIDACTIC, 

ren, my correspondent is carrying one now, and that most of her 
symptoms are referable to this fact. Women who have had child- 
ren that weighed nine pounds and over, very rarely have twins 
in a subsequent pregnancy.* 

The position of the foetus in utero would be more apt to modif}- 
the shape than the size of the tumor. The position of the child 
is so frequently changed, even up to the time that labor com- 
mences, that a constant and uniform increase in the size of the 
abdomen could hardly depend on this cause. 

The characteristic symptoms by which you would recognize an 
extraordinary enlargement of the abdomen, dependent on dropsy 
of the amnion, are the following. It is an acute affection, the 
tumor is circumscribed, disproportionate, is developed rapidly, 
and is most likely to occur in those who have previously had, or 
at the time are having, dropsy elsewhere. It almost never occurs 
in those who are not of a dropsical diathesis. To the hand, when 
placed upon the abdomen, the movements of the foetus seem dis- 
tant and indistinct. The foetus is almost always small, feeble, and 
illy-developed, and generally survives its birth but a short time. 
The tumor may develop to such an extent as to occasion the most 
alarming dyspnoea and syncope, by pressing upon the diaphragm 
and adjacent viscera. 

Intestinal disorder may produce an excessive enlargement of 
the abdomen in pregnant women, either by causing dropsy of the 
peritoneum, or by the inflation of the bowels with gas. In the 
former case the hepatic function is almost always implicated. In 
the latter the intestinal glandular apparatus. The symptoms 
would vary, and you would not fail to recognize them. 

Uterine and ovarian tumors would have a history that com- 
menced before pregnancy. Neither mal-formation, nor hydro- 
cephalus, nor general anasarca of the foetus, could be diagnosti- 
cated with certainty prior to delivery. Twin pregnancy might be 
detected through the foetal heart sounds. 

Prognosis. — It is an exceptional case for any woman to pass 
through the state of pregnancy, from beginning to end, without 
complaining of these or analogous symptoms. And, strange to 
say, the rule appears to be that, with certain qualifications, those 
who are most prone to these sufferings are least liable to have 

* At birth this patient's child weighed eleven pounds. 



ON THE DISEASES OF WOMEN. 69 

difficult labors, or tedious and dangerous convalescence in their 
lying-in. The chief danger from any of these symptoms, at what- 
ever period of gestation they may occur, is from abortion. If you 
can avert this calamity, the patient will probably do well. The 
greater the perturbation of the nervous system, or the more the 
urinary and hepatic functions are deranged, the more decidedly 
this unfortunate result is threatened. Dropsy of the amnion is 
more fatal to the child than to the mother. In all cases you 
should inspire your patient with courage, and with the hope that 
all may yet be well. A lugubrious, long-faced doctor would 
always be an additional affliction to her, but especially under 
these circumstances. 

Treatment. — The general indication is to make the woman as 
comfortable as possible, to turn aside the contingencies that 
threaten miscarriage, and to bring her through to term as quietly 
and safely as we may. To this end the directions which I gave 
you in my remarks upon the case that preceded this are equally 
appropriate here. 

The remedies indicated will vary with the special pathology of 
the case, or as the phrase is, with the symptoms presented. If 
the enlargement is due to abdominal or to amniotic dropsy, those 
remedies would be called for which are suited to the dropsical 
diathesis, and you would select from among them that one which 
is most appropriate to the symptoms of each individual case. I 
should caution you, however, against prescribing the apis mellifica 
in a low potency in case of dropsy of the amnion, lest it should 
precipitate a miscarriage. 

Incidental disorders of the intestinal tract suggest their own 
remedies, among the more prominent of which are arsenicum, 
chamomilla, nux vomica, mercurius, china, colocynth, belladonna, 
and veratrum. 

The pressure from a misplaced gravid uterus may sometimes be 
greatly relieved by a change of position on the part of the patient. 
Or bandages and supports, if properly adjusted, may tend to make 
life more tolerable, by allowing the patient to move around and 
to take exercise. They may also be made to add to the strength 
of the abdominal walls in case the child is preternaturally devel- 
oped, or where there are twins. 

I think that the induction of premature labor would not bo jus- 



70 LECTURES, CLINICAL AND DIDACTIC, 

tifiable in a case of this kind, unless the patient were in imminent 

danger from suffocation by dropsy of the am- 
^ h ilbo? uction ° fprema " n i° n * I can imagine, although I have never 

met with such an example in practice, that this 
expedient might be necessary as often, perhaps, as once in a thou- 
sand cases. Be sure you do not resort to it, gentlemen, on your 
patient's prescription instead of your own. 

Concerning the alleged power of pulsatilla to correct a mal- 
presentation of the foetus at any period of gestation, or in labor at 

term, I am wholly skeptical. Up to this date 
sent U at S ion" a " mal_pre ~ (Feb., 1869) there is not a single case on record 

which clearly proves it to be possessed of any 
such properties. In every published instance the testimony is as 
invalid and fallacious as in that which we have just had under 
review. This patient's physician was not certain in his diagnosis. 
First he said she had twins, then dropsy of the amnion, and finally 
the (one) child was " apparently across the pelvis." Pulsatilla 
was given, a spontaneous change followed — as has probably hap- 
pened with every foetus from the time of Cain until now — and 
the result was accredited to the remedy that had been swallowed ! 
Such things may not be impossible, but they are exceedingly 
improbable. 

SUDDEN SUPPRESSION OF MENORRHAGIA BY ASTRINGENTS THE 
CAUSE OF SUBSEQUENT ILLNESS. 

Case. — Mrs. R ■ desires relief from attacks of what has been 

diagnosticated as bilious colic, from which she has suffered at 
frequent periods for eight months. The paroxysms almost always 
come on at night, immediately upon retiring. For a week past 
they have returned every evening. The pain is referred to the 
epigastric region, and is described as sharp, cutting and colicky 
in its nature. It also intermits, and, when most severe, there is 
a slight inclination to vomit. The paroxysm generally lasts about 
an hour, during which time she cannot" lie down, but must sit 
upright in the bed. After the fit she sleeps soundly, and, with 
the exception of a loss of appetite for breakfast, and occasional 
headache, is quite well next day. It sometimes happens that un- 
usual excitement or fatigue will induce a paroxysm in the day- 
time. This trouble is greatly aggravated at each menstrual period. 
At present, the menses recur regularly every four weeks. 

Prior to the commencement of these attacks she had, for some 



ON THE DISEASES OF WOMEN. 71 

months, suffered from too frequent and too profuse menstruation. 
The flow returned every two or three weeks, and the loss of blood 
was sometimes extreme. To arrest the haemorrhage, her physician 
ordered vaginal injections of strong alum water. This expedient 
arrested the flow, but induced a severe attack of metritis, from 
which, in the hands of another physician, she barely recovered. 
The menstrual interval was subsequently extended to about four 
weeks, but the flow was still too profuse. All sorts of expedi- 
ents were tried to arrest it, but without effect, until the patient, 
becoming wearied with it, took the responsibility of resorting 
again to the alum injections. As soon as she did so, the exces- 
sive flow ceased, but in lieu of it she began to have these attacks 
of excruciating pain. During the eight months which have 
intervened she has had three other physicians, none of whom 
has succeeded in clearing up the diagnosis, or in curing the 
disease. 

The temptation to resort to astringents, topically and inter- 
nally, in case of haemorrhage, is a very strong one. This is espe- 
cially true in those forms of uterine haemorrhage 

Intra-uterine astringents. _ . _ . „, 

which are connected with menstruation, llie 
arguments against their indiscriminate employment are few and 
simple. In the first place, unless connected with abortion or labor 
at term, the excessive flow is symptomatic. In this case, to check 
it, and to arrest it by styptics, is not to cure the patient, but to 
complicate matters and make them worse instead of better. The 
more rational method would be to address our treatment, external 
or internal, or both, to the removal of the lesion, or condition 
upon which this flow depends. Take away the cause and the 
effect ceases. To strike this single symptom out of existence 
would be to lose time and work mischief. 

Again, a copious menstruation, like a free diuresis or diaphor- 
esis, may be critical, and in a sense salutary. It may represent a 
species of safety-valve which, for the welfare of 
crkicaT rhasia sometimes the general organism, should not be too ab- 
ruptly closed. It is quite probable that the 
menstrual secretion is partly eliminative, and designed to expel 
€ertain noxious matters which would prove harmful if retained. 
To suppress the flow voluntarily might induce the very symptoms 
which are present in case of retention from diseased states, a con- 
sequence which it is our duty to avert. 

You will readily perceive that the sudden application of a solu- 



72 LECTURES, CLINICAL AND DIDACTIC, 

tion of alum to the vascular mucous membrane of the superior 
vagina and uterine cervix, for the arrest of the 

Physiological argument ' .. , , , - 

against intra-uterine as- haemorrhage, would be very apt so to derange 
its capillary circulation as to cause inflamma- 
tion. If you desired to produce an attack of metritis, no more 
certain and expeditious method could be devised. It is no marvel 
that this poor woman suffered greatly, and almost died in conse- 
quence of this unwarrantable expedient. Thousands of lives have 
been sacrificed in this very manner. These harsh astringents are 
often thrown into the vagina, and sometimes even into the womb 
itself, for the same purpose as in this case. With utter disregard 
of the delicacy of the structures involved, of the danger of inflam- 
mation and its sequelae, of the risk of throwing the fluid through 
the Fallopian tubes directly into the cavity of the peritoneum, of 
damming up the blood upon the ovaries, of pelvic hematocele, 
and other consequences a hundred fold more serious than the 
haemorrhage itself, this practice is still sanctioned by the profes- 
sion. I have brought this case before you, in order to impress 
upon your minds some of the possible consequences that may result 
from such treatment ; also to show you " a more excellent way." 
We shall doubtless have frequent occasion to refer to the reflex 
relations existing between the uterine cervix and the stomach. 
There is much that is curious and suggestive 

Digestive disorders from . . ,..,,. , 

vaginal and uterine injec- therein. J3ut there is a clinical hint connected 
with the history of cases like this, the signifi- 
cance of which you should appreciate. A large proportion of the 
cases in which astringent injections of various kinds have been 
thrown into the vagina, and thus brought into contact with the 
neck of the womb, are characterized by peculiar and inveterate 
disorders of the stomach and bowels. Some of the worst examples 
of gastric indigestion that I have ever treated were chargeable to 
vaginal injections that had been resorted to for the cure of leucor- 
rhcea. In other cases, the ill effects have been observed in the 
production of intestinal colic, dyspepsia, and constipation. 

Here the irritant is applied to the superior vagina and about the 
cervix. Through nervous sympathy the stomach and bowels are 
implicated. Their functions are deranged, and more or less of 
actual suffering is induced. Such a train of consequences is all 
the more certain and characteristic, if the drug with which the 



ON THE DISEASES OF WOMEN. 73 

injection was medicated had also a specific relation to some por- 
tion of the intestinal tract. And, upon reflection, you will find 
that a majority of the substances used in this manner have such a 
relation to the alimentary system especially. It is true of tannin, 
alum, the acetate of lead, the salts of silver, of copper, and of iron, 
the oil of turpentine, and many other remedies which have been 
used in this way. This explains the possibility that our patient 
first experienced her attacks of "bilious colic," falsely so-called, 
in consequence of the alum injections, which had been taken to 
suppress the haemorrhage from the womb. 

But there is another item which we must not pass over in 
silence. I allude to the fact that menorrhagia sometimes 
depends upon the presence of uterine polypi, 
^Menorrhagia from polypi, w hich, being very vascular, occasion the in- 
creased and prolonged haemorrhage at each men- 
strual period. And not only so, but they sometimes cause a spe- 
cies of menstrual colic, which greatly torments the patient. I have 
repeatedly had occasion to witness the most extreme suffering, 
sometimes gastric, again gastro-intestinal, or perhaps uterine 
chiefly, which was entirely due to the presence and pressure of a 
polypoid growth within and upon the cervix. Indeed, when I 
find a patient complaining of these symptoms, and learn that she 
has not been in the habit of taking vaginal objections, I am suspi- 
cious of the existence of some intra-uterine growth, which may be 
sufficient to account both for the menorrhagia and the spasmodic 
colic. And I recommend you, gentlemen, to be upon your guard 
in all cases of this kind. Do not trust too exclusively to objec- 
tive symptoms, which might mislead you, and bring down reproach 
upon your school and your skill. Examine the case thoroughly,, 
and do not forget the practical hints of which I have just spoken. 

Treatment. — This is a case of neuralgia of the cceliac plexus , 
induced by the alum injections. How shall we treat it? Is it 
worth while trying to antidote the poison thus introduced, when so 
long a time has elapsed since it was taken ? Or shall we prescribe 
for the symptoms as we find them ? This is a point upon which 
doctors would assuredly disagree. My own opinion is that, if the 
attack were more recent in its origin, and we had a reliable anti- 
dote for the toxical -effects of alumina, the " chemical treatment,'' 
as it is called, might promise good results. But, under the cir- 



74 LECTURES, CLINICAL AND DIDACTIC, 

cumstances, we must base our prescription upon present indica- 
tions. 

The character of the pain, the period of its recurrence, the 
causes that induce it incidentally, and the aggravation at the men- 
strual period, are the prominent and most significant symptoms. 
Pulsatilla is the remedy. I recommend that she take a dose of it 
every three hours during the day. If the paroxysm returns at 
evening, it may be repeated esreij twenty or thirty minutes until 
the attack has passed. When the symptoms are relieved, the med- 
icine may be given at longer intervals. I have sometimes cured 
this species of neuralgic colic, dependent upon maltreatment of 
uterine affections, by giving a few doses of atropine 3d, and again 
with colocynth of the same potency. 

There are cases of reflex disorders in other organs, as for exam- 
ple the stomach and bowels, the head, the heart, and the general 
nervous system, but more especially in the ova- 
intolerance of vaginal r i es ^hat will not yield to the best chosen rem- 

injections. J 

edies until the habit of taking vaginal injections 
is proscribed. This remark applies not only to injections that 
are harsh and decidedly irritant, but also to such as are ordinarily 
harmless. These cases are exceptional, and should not tempt you 
into an indiscriminate denial of the efficacy of such means under 
proper indications. It will be best for this patient not to take any 
kind of vaginal injection until she has recovered her health, and 
then only for the purpose of cleanliness. 

Should these means fail, it would be proper to proceed upon the 
hint which I have given you concerning the possibility that there 
is a foreign body, a polypus, within the womb. The os should be 
so dilated with a sponge or other tents, that the proper exploration 
can be made. This should be done slowly and carefully, in the 
manner which will be detailed when I come to speak of the treat- 
ment of uterine polypi. 



ON THE DISEASES OF WOMEN. 75 



LECTURE IV. 

uterine haemorrhage aeter twin delivery. 

Gentlemen : 

I will embrace this opportunity to speak to you of the following 
interesting 

Case. — Mrs. , in her fourth labor, was delivered of twins, 

the united weight of the children being eighteen pounds. The 
labor was of only three hours' duration, both children presenting 
by the head. The placenta, which was a very large single mass 
with two separate cords, was carefully removed twenty minutes 
after the birth of the second child. Considering its great size, the 
womb appeared to contract properly while the placenta was being 
extracted. But, two minutes after it was taken away, the patient 
was seized with vomiting, which was immediately followed by a 
fainting fit. The retching and syncope continued to alternate 
every few seconds. She became pale and pulseless. I placed my 
hand over the uterus and found it flaccid and relaxed, instead of 
firm and contracted as before. It felt as if the finger could be 
thrust through it with very little effort. Blood was flowing fear- 
fully from the vagina, and my patient was insensible. The pains 
had entirely ceased. 

I removed the pillow from beneath her head and placed it trans- 
versely under the hips, after which I at once resorted to friction 
and kneading of the abdomen with my left hand, while, with the 
right one, large pieces of ice were passed high up into the vagina, 
and even through the gaping cervix quite into the womb. In all, 
a lump of ice as large as the nurse's head — the chignon included 
— was thus applied. The patient made no resistance and offered 
no complaint, being meanwhile more like a dead than a live 
woman. Just in proportion as the womb contracted upon itself, 
the flow ceased. After more than half an hour of the greatest 
anxiety to the husband and family, and of extreme danger to my 
patient, she opened her eyes, in a semi-conscious state, and asked 
" why everything that flowed from her was so cold?" As soon 
thereafter as it was safe to move her in the least, the binder was 
snugly and firmly applied over a dry compress, and, with great 
subsequent care, she made a good recovery. 



76 LECTURES, CLINICAL AND DIDACTIC, 

In the whole range of medical and surgical practice there is 

nothing more alarming and serious than a bad case of flooding after 

delivery. And there is no position in which the 

Alarming nature of uter- c j ctor can be placed where his coolness and 

ine haemorrhage. *• 

skill, his self-reliance and tact, maybe of greater 
service to his patient. Although they are by no means frequent, 
still, since it is possible that such a case may be one of the first 
to which you will be called, it is alike your duty and mine to con- 
sider this subject carefully. For the physician must be au fait, 
ready at a moment's notice, to act promptly and efficiently. 

In general, uterine haemorrhage is more apt to occur after rapid 
labors. In this respect the same rule holds as in the case of after- 
pains — the shorter the labor (in multiparae), 
incident to rapid labors -j-^g more severe and protracted the subsequent 

especially. -l u 

pains, and vice versa. The cause is probably the 
same, both in case of the haemorrhage and of the after-pains. 
When the labor is quickly over, and the uterus has been rapidly 
emptied of its contents, its muscular fibres have contracted less 
firmly than they would have done in an opposite state of things. 
Hence the mouths of the vessels, which were ruptured at the site 
of the placenta, are not closed and sealed as tightly as they should 
have been. A sudden and fearful haemorrhage may be due to this 
cause alone. 

This accident may also be occasioned by adhesion of the pla- 
centa throughout nearly its whole extent. If it begins to be de- 
tached at the border, and then remains partly 

Adherent placenta a cause. 1 . 

adherent, alarming haemorrhage is very apt to 
result. If it is first separated from the uterine wall at the middle 
of the placental mass, a clot may form at that point, and arrest the 
flow of blood by direct compression. This last is the usual man- 
ner of separation of the after-birth. If the placenta is very large, 
as in this case of twins, and so extensively attached as almost to 
cover the entire surface of the womb — as in certain of the infe- 
rior animals — the liability to haemorrhage when it is torn off, or 
comes away, is very much increased. The larger the extent of 
uterine surface exposed, and especially if the womb has been very 
much distended, and its walls are flaccid, the greater the danger 
of and from post-partum haemorrhage. Hence this mishap is a 
more serious affair in case of twins than where there is only one 



ON THE DISEASES OF WOMEN. 77 

child, and the larger the children the greater the danger there- 
from. If only a small portion of the secundines remains, it may 
be sufficient to cause the most dangerous haemorrhage. 

Haemorrhage is sometimes due to uterine inertia. Here the 
entire expulsive power of the organ has been spent in effecting 
delivery. To fold the womb upon itself, and 
inSda orrhage from uterine to constringe and compress the gaping vessels, 
requires an additional supply of motor force. 
But it is not forthcoming, and flooding is the indirect consequence 
of protracted, tedious, and difficult labor. These cases are excep- 
tional, but they do sometimes occur. 

The presence of clots in the uterus, or of a clot in the os uteri, 
may give rise to flooding. They operate by interfering with and 
preventing the complete contraction of the womb. Other causes 
to which this result may sometimes be referred are a cough, dis- 
tention of the bladder, partial inversion of the uterus, rupture 
of the placenta, cancer of the womb, uterine polypi, and albu- 
minuria. 

Women of a hemorrhagic diathesis are predisposed to this 
complication of labor. Those who have had haemoptysis, or 
haematemesis, need especial care during and 
thJsk e apred2pon^t dia ~ subsequent to delivery, in order to avert it. 
The same is true of those who flow very freely 
at each menstrual return, or who have ever had menorrhagia. It 
is my habit, when the patient is a stranger to me, always to inquire, 
before the delivery of the placenta, whether she has been subject 
to either of these forms of haemorrhage, and also whether she 
flowed profusely in her previous confinements. For those women 
who have had one attack of post-partum haemorrhage, are exceed- 
ingly liable to another. 

Prognosis. — In all those cases in which the loss of blood is not 
promptly recognized and proper measures taken for its arrest, 
there is great danger. Other things equal, the more rapid the 
labor the greater the danger. So, also, of the relative size of the 
womb. Vomiting is salutary, and not by any means a bad sign, 
when it follows the haemorrhage, for in this case it may stimulate 
uterine contractions, and thus help to save the patient. But 
when it precedes the haemorrhage, it is less favorable. Hero it 
depends on the emptying of the womb and the removal of the 



78 LECTURES, CLINICAL AND DIDACTIC, 

accustomed pressure by other organs. Patients sometimes swoon 
away and die in the first fit of syncope. If, however, they sur- 
vive one or more of these fits, the case becomes more promising. 
It is a bad sign if the fainting and flooding continue to alternate. 
In all cases the danger is proportionate to the atony of the 
uterine muscular fibre, the irregularity of its contraction, the pain 

which the patient experiences (if she is not 

insensible) the more or less complete delivery 
of the placenta and the membranes, and the time that has elapsed 
since the close of labor. The harder, more unyielding and globu- 
lar the womb feels, through the abdominal parietes, the less the 
danger. If, however, the fundus is felt near or above the umbili- 
cus, and the womb does not contain another foetus, there is great 
risk from internal haemorrhage, which may be due either to great 
distention of the bladder, or to a retention of a part of the 
placenta, or of the membranes. With certain qualifications, the 
greater the pain, resembling labor pains, the less the danger from 
haemorrhage. The danger is also diminished by the length of 
time that has elapsed since the labor proper was completed. Con- 
vulsions, due to a sudden haemorrhage of this kind, are almost 
invariably fatal. 

The risk to the patient is not always removed when the haemor- 
rhage is under control. It may take months, or even years, for 

her to recover from the loss of so much blood. 

There is danger from puerperal phlebitis, cellu- 
litis, pelvic hematocele, pyaemia, and also from the formation of 
abscesses in various parts of the body. Added to this are the 
mischievous contingencies which beset the suppression of the 
milk and the lochia, and the fact that the nutritive system of the 
mother has long been taxed severely for the development of the 
foetus in utero. 

You will not, therefore, be justified in promising to cure every 
case of this kind, even although you may have been so skillful 

and successful as entirely to control the haemor- 

A qualified prognosis. . _ . ' 

rnage. It is best m every instance to qualify 
your prognosis, and to allow sufficient time for your patient to 
recover, providing she really does get well. 

Treatment. — Bear in mind that I am speaking of a very extreme 
case of post-partum flooding, not of placenta praevia, nor yet of 



ON THE DISEASES OF WOMEN. 79 

those mild cases of haemorrhage which are more frequently met 
with and more easily managed. Teachers and authors almost 
always confound them, to which fact we may attribute the con- 
fused ideas in theory and practice that are generally entertained. 
Authors are not agreed concerning the relative value of inter- 
nal and external, or constitutional and manual means for the 

arrest of the flow in a case like this. Some 
^internal and local treat- i ns i s ^ that local measures are indispensable and 

sufficient, and that medicines internally given 
have little or no effect. Opposed to this class are those who hold 
the extreme view that this accident should be treated by internal 
remedies exclusively.* As usual, the proper course appears to lie 
between them. Both classes of measures may be requisite, and 
we should not extol the one at the expense of the other. Passive 
haemorrhage from the womb implies a diseased state, which may 
have developed into, or from, a dyscrasia, and therefore comes 
properly within the domain of constitutional treatment. But in 
a case of sudden flooding, directly connected with delivery and 
rupture of the vascular attachment between the uterus and the 
placenta, where the blood flows from the vulva like water from a. 
pump, and where life is jeopardized, and may be lost in a twink- 
ling, other and very different indications are presented. Let us 
see what those indications are. 

Whether from a sudden emptying of its contents, or from the 
exhaustion consequent upon protracted and difficult labor, uterine 

inertia always implies an imperfect contraction 

Obvious indications. _ . 

oi the womb. Labor proper being passed, the 
uterine effort is brought to a stand-still. The veins, or sinuses, 
at the site of the placental attachment have been mechanically 
ruptured. Unless these torn vessels are compressed, and ligated, 
as it were, by the uterine contractions, there is nothing to prevent 
or to obstruct the flow, and death may speedily ensue. Hence the 
paramount indication is to bring on these contractions as speedily 
as possible. " A pint of blood saved, and a pint of blood lost to 
the patient, may make all the difference between a rapid and a 
tedious convalescence — may make all the difference between a 
successful and a fatal issue." 

* Vide Dr. Guernsey's paper and the discussion thereon, in the Transactions of the 
American Institute for 1869. 



80 LECTURES, CLIXICAL AXD DIDACTIC, 

The first thing to be done is to lower the patient's head to a 

level with, or even lower than her hips. Then grasp the uterus, 

through the abdominal walls, with one or both 

Promote uterine con- h an d s . Hold it firmly. Make steady and 

traction. ^ ^ ^ 

equal pressure, noting carefully if it contracts 
regularly, is becoming smaller in size, and less flaccid and relaxed. 
If it is, all is going on well ; if it is not, otherwise. 

If the flow continues, leave one hand (usually the left) on the 
abdomen, and explore the uterus internally with the other. If 

the placenta has not been delivered, and is only 

partially detached, give the patient a plump 
dose of brandy and water, and then pass the hand into the womb 
and remove the after-birth. Peel it off by insinuating the fingers 
between it and the internal uterine surface. And don't bring 
away the hand until you bring the whole placenta along with it. 
Be careful, however, not to invert the womb. In these cases the 
placenta is frequently retained in consequence of the paralysis of 
the uterine muscular fibre, and not always because it is morbidly 
adherent. Remove the clots from the os and uterine cavity 
also. 

The proper course is not to put on the binder while the haemor- 
rhage continues so profuse. The hand, when applied over the 

abdomen, may first have been dipped in cold 

Available expedients. .. . _ 

water. Or cold cloths may be applied to the 
vulva. Pieces of ice, when they can be had, may be introduced 
into the vagina, and, in exceptional cases, even carried up to the 
fundus of the womb. Or ice-water may be injected into the 
uterine canity, the vagina, or the rectum. Pouring cold water 
from a height upon the abdomen, although efficient, may do mis- 
chief indirectly, by wetting the clothing and causing the patient 
to take cold. Colpemysis, which consists in introducing the col- 
peurynter per vaginam, and filling it with ice-water, is also an 
available and excellent expedient. It not only supplies the shock 
from the cold, which is so useful, but also serves to stimulate the 
reflex contractions of the uterus, much as the child's head would 
do, if it were still in the vagina, and thus to put a stop to the 
flow. 

There is a great aversion on the part of many physicians to the 
introduction of the hand into the uterus. The danger therefrom 



ON THE DISEASES OF WOMEN. 81 

Is more imaginary than real. It is true that the cases of uterine 
haemorrhage in which this expedient is requisite 

The hand in utero. 1 . 

are not very numerous, but they do certainly 
occur. Earle, who is very emphatic on this point, says :* 
*' I have noticed, and it is what we should expect, that the men 
who deprecate the procedure are generally those who possess big 
hands." When the hand is placed within the womb, it stimulates 
immediate contraction. The organ closes around the hand just 
as it did around the fcetus, and this involution, closure or con- 
traction, is the great haemostatic. 

Now, since the os sometimes closes very soon after the delivery 
of the secundines, and since the longer you delay the greater will 
he the difficulty in inserting the hand at all, and the greater the 
danger from internal haemorrhage also, if the symptoms do not 
yield readily and promptly to other measures, the sooner you 
resort to this expedient the better. If any portion of the pla- 
centa remains, remove it ; if the womb contains one or more clots, 
remove them. If you can find the spot from which the flow 
comes, and can compress it between the hand within the womb 
and that upon the abdomen and over it, do so. Firm pressure 
over the fundus and towards the pubes will help to empty the 
womb of the clots which it may contain. 

Gooch, who is excellent authority, gives the following testi- 
mony concerning the efficacy of pressure by the hand directly 
upon the denuded portion of the uterus : f 

" My belief now is, that when haemorrhage occurs after the 
removal of the placenta, the quickest way to stop it is to intro- 
duce the left hand closed within the uterus, apply the right hand 
open to the outside of the abdomen, and then between the two 
to compress the part where the placenta was attached, and from 
which chiefly the blood is flowing. When the hand is introduced 
merely as a stimulant, there is an interval of time between its 
arrival within the uterus and the secure contraction of this organ, 
during which much blood is often lost. By directing the hand to 
the very vessels from which it issues, and compressing them as I 
have described, this quantity is saved. If I may judge by my 

* On Flooding after Delivery, etc. By Lumley Earle, M.D., etc. London. 1S65 ; 

P- 77- 

f An Account of some of the most important Diseases peculiar to Women. By 
Robert Gooch, M.D. Philadelphia. 1848. Second Edition ; p. 300. 
6 



82 LECTURES, CLINICAL AND DIDACTIC, 

feeling, the blood stops, in a great degree, even before the uterus 
contracts ; the hand acts first as a tourniquet, then as a stimulant. 
It is true we can not tell with certainty where the placenta was 
attached, and consequently where the pressure should be applied, 
but as it is generally attached to or near the fundus, if the pres- 
sure be directed there, it will generally be right. Besides, after 
the child is born, it is often several minutes before the placenta, 
separates and descends ; if, during this interval, we pass the finger 
along the cord and observe, at its entrance into the uterus, whether 
it turn towards the front, the back, the right or left side, or straight 
up to the fundus, we shall form a tolerably exact idea of the spot 
to which the placenta has been attached in this individual case." 

"Where the uterine atony is very marked, and there is reason to 
fear that the haemorrhage may return, the ergot is an excellent 
remedy. You may give it in a low potency, or, if you please, in 
substance. The fluid extract, the tincture, and the wine of ergot 
are not reliable. If you prescribe the drug with a view to its 
prompt, tonic effect, and with the intention of causing the womb 
to contract firmly and securely, give ten to twenty grains, freshly 
powdered, in a little warm water. It may happen that you will 
not have occasion oftener than once in ten or twenty years to 
resort to this expedient, but I charge you not to forget it. 

In these extreme cases of post-partum haemorrhage, stimulants 

should be given very freely and frequently. This is especially 

requisite where the flow occurs in those who 

Stimulants. 

have been uncier the influence of chloroform or 
ether. Brandy is best of all, after which come whisky, ammonia, 
and camphor. There is no danger from the reaction which may 
soon after follow. Fresh air is equally necessary. 

Do not, for any possible reason, allow the patient to sit up in 
the bed, or she may fall at once into a mortal syncope. Keep her 

as quiet as possible. If she faints, lower the 

Keep the head low. * .,, 

head still more. If she vomits, turn it gently, 
but do not raise her shoulders. Examine from time to time, and 
learn for yourself if the flow is ceasing. 

If she has not urinated for some time, or there is reason ta 
believe that the bladder contains a considerable 

Emptying the bladder. 

quantity of urine, draw it off by means of the 
catheter. And do not forrret that this condition is apt to be pres- 



ON THE DISEASES OF WOMEN". 83 

ent whenever the uterus, instead of contracting in a globular form 
just above the pubis, is high up towards the umbilicus, and pointed 
in its outline. 

Although for more than thirty years an effort has been made 

on the part of some prominent members of the profession to do 

m away with the use of the obstetric binder, the 

The value of the binder. . . 

general sentiment and practice is still in favor 
of its employment. When carefully and properly applied, there 
is really no valid objection to it. The arguments against its use 
are founded upon its abuse in the hands of those who have been 
careless and are unskillful. In cases like the one we lurve just 
studied, it affords an additional safeguard, and a means of com- 
fort, which, while it does not in any manner interfere with the 
internal treatment, could not be substituted by anything else. As 
I have already hinted, in general the bandage should not be 
applied until the globular form of the uterus has been recognized 
through the abdominal parietes, and the haemorrhage has measur- 
ably ceased. Until this period, in a bad case of flooding, the hand 
should not be removed from the hypogastrium. 

The objections that have been urged against the binder apply 
more properly to the compress which is beneath it. If not care- 
fully adjusted, this may do real mischief by 

The compress. . /» • • i i • -i • r» i i i 

interfering with the proper circulation ot blood 
in the pelvic and abdominal organs, and by displacing them. You 
should never make use of it without being careful to recognize 
any change in the position of the uterus, especially in the direc- 
tion of latero-version, in which case it will be necessary to replace 
the bandage directly over the front face of that organ, wherever 
that may be. Of course it need not be of so firm and unyielding 
a texture as to injure the soft parts. In most cases it may consist 
of an ordinary dressing towel, folded several times. In ordinary 
labors, without subsequent haemorrhage, I dispense with the com- 
press and make use only of the binder. Yet in, or rather after 
flooding, I have great confidence in the additional application of 
the compress with the binder. 

In illustration of the value of these adjuvants, the following- 
case occurs to my mind. One of my medical 

A rare expedient. . ,.,.,. , r> i 4.1 

friends, while ruling past a farm-house on the 
prairie, was hastily summoned to the bedside of a lying-in woman. 



84 LECTURES, CLINICAL AND DIDACTIC, 

who had just been delivered of a bouncing baby. She was almost 
dead from the loss of blood, which had run through the bedding, 
and stood in pools upon the floor. She was bloodless, pale, cold, 
and gasping for breath. Equal to the emergency, my friend seized 
the family bible and bound it very tightly over the womb with a 
coarse towel. This severe compression stopped the haemorrhage 
almost instantly, and saved the woman's life. I do not recom- 
mend you, gentlemen, to employ books as uterine haemostatics in 
ordinary cases of flooding, but to carry about with you, and to 
cultivate, that species of inspiration which seizes upon every 
variety of remedial resource, and puts it to the best possible use. 

PSEUDO-PROLAPSE OF THE UTERUS. 

Case. — At five p.m., of June 4, 1866, I was summoned in haste 

to visit Mrs. , who, the husband wrote me, was " almost dead 

with prolapse of the womb." In his note he requested me to 
bring the necessary instruments for replacing that organ. The 
patient, aged 52, had been ill one week, under the care of two 
physicians who had diagnosticated the case as one of prolapsus 
uteri, and who, I was told, had several times restored the womb 
to its normal position. These operations had caused her great 
pain, and she had a mortal dread lest I should think it necessary 
to repeat them. The day previous, the doctor had succeeded in 
introducing a Hodge's lever pessary, which, after a little, dropped 
out of itself. Although she had taken opiates freely and fre- 
quently, she had not slept for two days and nights. There was 
retching and bilious vomiting, and, although she had taken cathar- 
tics, the bowels had not been opened for four days. There was 
much ineffectual tenesmus, and with each effort at stool she com- 
plained of feeling as if the uterus and neighboring organs would 
be expelled from the body. She was exceedingly nervous, and at 
intervals of five to fifteen minutes suffered acute pains across the 
inferior portion of the abdomen. These pains were aggravated 
by motion and by any considerable degree of mental excitement. 
She described them as short, sharp, spasmodic, cutting and col- 
icky in nature. She was greatly depressed in spirits — "must 
have relief or she should die." 

I enjoined rest, as first and most important. Belladonna 3d, 
and mix vomica 3d, were to be taken in hourly alternation until 
the symptoms improved, after which they were to be repeated 
every two hours. If she slept, she was not to be awakened or 
disturbed. If the bowels did not move before daylight, they 
might give her an enema of tepid water. I made no examination 
per vaginam. 



ON THE DISEASES OF WOMEN. 85 

June 5, 5:30 p.m. — Patient better. After taking the first dose 
of the belladonna she slept for some minutes, and had but one 
more spasm of the pain. The remedies were repeated only at 
long intervals, for she slept quietly during the greater part of the 
night. At daylight, not having had a stool, the enema was admin- 
istered with good effect, although the passage was very painful, 
and she was much exhausted in consequence. The tenesmus and 
vomiting were relieved, and she declared herself well. Continued 
the same remedies once in four hours. The "touch" revealed 
the uterus in situ. The husband and family were delighted with 
the promptness of the relief afforded. 

Two days later this patient was able to attend to her household 
duties. 

Nothing is more common than a temporary prolapse of the 
womb. Some women have it at each menstrual period ; others 

after any extraordinary fatigue, as in walking 
P roia e p^? ncy ° f uterine or riding 5 some from a fit of mental anxiety or 

of coughing ; others after a stool ; and others 
again after coitus. When induced by these causes it is a self- 
limited affection, and may pass away with rest in the recumbent 
position. This is a very different thing from a chronic and invet- 
erate prolapse, and requires very different treatment. If my 
predecessors had recognized this fact, this patient would have 
improved before I came ; for in that case they would have for- 
borne to do anything mischievous. A correct knowledge of 
special pathology on the part of the physician is sometimes an 
excellent safeguard for the patient. 

One of two ill results may follow a wrong diagnosis in cases of 
this kind. Either the slight and temporary displacement may be 

converted into a permanent one, with all its 
dk°nosls Uencesofincorrectconse( l uen ^ suffering and disorder, by reason of 

a harsh and inappropriate treatment ; or it may 
happen that harmless and inefficient means may get the credit of 
holding some specific curative relation to uterine deviations of 
whatever kind. 

Nothing could be more cruel, harmful and unnecessary, than to 

resort to manual treatment in such a case as 

Unnecessary manipula- £his, { n £he staffe in which I foillld it. WllV 

tion. ' O 

explore and worry such a sensitive womb with 
the sound ? Probing will not relieve these acute symptoms, and 



86 LECTURES, CLINICAL AND DIDACTIC, 

a pessary would be about as useful as a fracture box in inflamma- 
tory rheumatism. 

Opiates might deaden the sensibilities, but they are possessed 
of no curative relation to the symptoms detailed, and would indi- 
rectly unhinge the nervous sympathies more 

Harmful medication. t/»i i i 

and more, it the cathartics operated at all, the 
effect would be, by increasing the peristaltic action of the intes- 
tines, to increase the uterine displacement and to render it more 
permanent. There is no question, in my own mind at least, that 
very many examples of confirmed prolapsus have been entailed 
upon our patients by such inappropriate and inexcusable treat- 
ment at the hands of those who have preceded us. 

On the other hand, the fact that such cases may get well of 
themselves, providing we do nothing to interfere therewith, is too 

frequently lost sight of by our physicians. 
qu S acki 1 shdaims C . ures and Every kind of remedy has thus been given and 

extolled as a specific for uterine deviations. You 
will find the most incredible stories of cures with this or that dilu- 
tion detailed in our books and journals. Perhaps a single dose 
has worked the most marvelous results, the womb being replaced, 
according to the report, almost as soon as the medicine was swal- 
lowed, no allowance being made for the tendency to a spontane- 
ous reduction of the dislocation, the self-limited nature of the 
attack, or the good effect of rest in the proper position. 

When carefully chosen, it is reasonable to suppose that our 
remedies are capable, in many instances, of curing what might 

otherwise develop into a troublesome case of 
in A pro'Sp r s e u^. edies may d ° uterine prolapse. We may sometimes avert 

such a consequence of neglect, or of ill treat- 
ment, in much the same manner as we prevent a case of pulmon- 
ary congestion from resulting in pneumonia. It is possible, by 
this means, to spare our patients much suffering, and frequently 
to turn aside what would otherwise be a real calamity. I cannot 
claim that belladonna is a specific for any form of uterine luxa- 
tion, but I may insist that it was adapted to the relief of the pecul- 
iar incidental symptoms of which this patient complained. Nux 
vomica will not go to work like an intelligent agent to restore the 
fallen womb to its proper position, but it holds a specific, patho- 
genetic relation to the incidental symptoms in many cases of the 



ON THE DISEASES OF WOMEN. 87 

land. And so of podophyllin, sepia, calcarea carb., and many 
other remedies. We must select the remedy according to the 
symptoms that are present, just as in case of incipient pneumonia, 
or pleurisy. In this stage, the proper treatment is medical, and 
not surgical. 

Whether you should alternate remedies, as it seemed best for 
me to do in this case, your own observation must help you to de- 
cide. It would be very wrong to claim that 

Alternation of remedies. _ .. rv» i • i • 

cures have not been effected m this manner, 
and equally at variance with truth to assert that careful study 
and close observation do not lead a majority of practitioners more 
and more to prefer the single remedy. 

HYSTERIA IN A WOMAN AGED SIXTY. 

Case. — I was called, during the night of August 20, 1857, to 

visit Mrs. , aged 60. She was in a semi-conscious state. At 

intervals of from two to five minutes she had spasms which 
affected chiefly the neck and superior extremities. During these 
spasms both the fingers and the wrists were very much flexed. 
The arms and hands trembled constantly. The pulse continued 
quite regular and uniform, both during the paroxysm and in the 
interval. The eye was slightly suffused, but otherwise natural ; 
the pupil being neither dilated nor contracted. When the parox- 
ysm subsided, she became very restless, and moaned and wept 
immoderately. I observed that by directing the conversation to 
other matters, leaving her condition and surroundings for foreign 
topics, the duration of the interval between the fits could be con- 
siderably prolonged. She had been very much exercised and ex- 
cited over the proposed marriage of a daughter, to which she was 
opposed, and for three days had neither slept nor eaten. 

I ordered a cup of strong coffee — for I knew that she could 
not drink this beverage in health without becoming exceedingly 
nervous and wakeful. Of this she took two teaspoonfuls once in 
ten minutes. She had only a slight spasm after the first dose, and 
in half an hour had fallen quietly asleep. 

The next morning she felt greatly refreshed by her night's rest, 
but was still somewhat weak and exhausted. She had an indis- 
tinct recollection of my having been in her chamber the night pre- 
vious, but knew nothing of having taken the coffee. I ordered tea 
instead of coffee, a generous diet, and for the future less excite- 
ment and fatigue. She recovered promptly without medicine. 

. As a rule rrysteria occurs only in those women who have not 



88 LECTURES, CLINICAL AND DIDACTIC, 

ceased to menstruate. Occasionally, however, we meet with well- 
marked examples thereof before puberty, and 
Hysteria incident to men - a f^ er ^} ie climacteric. It is rare to find an 

strual life. 

example of this strange affection in one who is 
more than fifty years of age. I will not detail the clinical history 
of this disease at the present time, but direct your attention to- 
one or two points of practical interest in the case before you. 

We make a distinction between spasms and convulsions, which 
it will be well for you to bear in mind. Spasms are not necessa- 
rily, or even generally, accompanied by an entire 

Spasms or convulsions ? ' „ . ,-p,, . . „ . 

loss oi consciousness, lneir maniiestation is 
local and temporary. They leave the patient quite decidedly, 
and she becomes almost, if not altogether, rational in the interval. 
Convulsions, on the contrary, are soon, if not from the outset,, 
characterized by a complete obliteration or suspension of the per- 
ceptive faculties. The patient knows nothing of what is going 
on around her. She may remain as oblivious during the interval 
as in the paroxysm. Convulsions are accompanied by a more 
general derangement of muscular action. The spasmodic move- 
ments are less apt to be local, and more frequently implicate the 
different sets of voluntary muscles in succession, beginning with 
those of the head, neck, and superior extremities. 

If you examine the eye of an hysterical subject, you may find 
that it is not changed in its appearance. The pupil is neither 
dilated nor contracted. Sometimes the eye is 
suffused, and the ball may be rolled upwards. 
Now and then there will be a marked difference in the size of the 
pupils, but this may or may not be pathognomonic. I am not aware 
that any author has observed this as a symptom of hysteria, but I 
am inclined to think that it is possessed of some significance as a 
diagnostic sign. 

Add to this that you may sometimes detect the patient looking 
at you askant, or slyly listening to what you say, breathing more 
Th atient , regularly and freely, or having her spasms at 

longer intervals, when she discovers that you 
are quietly busying yourself with other topics of conversation. A 
little tact will sometimes enable you to cut the Gordian knot of 
diagnosis in the most complicated cases of this kind. 

If the pulse is not perturbed, but keeps the even tenor of its. 



ON THE DISEASES OF WOMEN. 89 

way, during both the paroxysm and the interval, it is an almost 
positive sign of hysteria. If the attack is refer- 
able to emotional causes, acting upon a too sus- 
ceptible organism, the nervous symptoms that follow will almost 
certainly be tinted with some peculiarities. Loss of sleep is a 
powerful predisponent of this disease. 

Treatment. — Tact is no less important in the treatment than in 

the differential diagnosis of hysteria. In no other disease is it of 

more practical moment to be personally ac- 

Valueoftact. . , . , . x „ , , 

quamted with your patient. Ii you know her 
peculiarities beforehand, the case may be said to be half cured at 
the outset. There are a thousand little items which the physician 
who is observant gathers up and stores away against a time of 
need. And it often happens that what would appear trivial, turns 
out in the end to be most significant and useful. For, in this 
manner, he may not only interpret the meaning of certain extra- 
ordinary and alarming symptoms, when they are present, but may 
be led at once to the selection of the remedy proper to the case. 

However much we may pride ourselves upon our scientific 

attainments, I assure you that our patients are prone to estimate 

our professional capacity and skill, by our abil- 

vaiue of impromtu re- ^y to turn all sorts of expedients to the best 

sources. J -l 

account, at the shortest possible notice. They 
will think more of you, if you can effect a cure with some simple 
and harmless domestic remedy which they have overlooked, like 
the coffee in this case, than if you go through the labor and take 
the time and pains to select the appropriate simillimum. Keep 
your quiver full of arrows, and be ready for any emergency. 

I know of no remedy so well adapted to the relief of nervous 
symptoms, caused by mental fret and friction, and accompanied by 
insomnia, or wakefulness, as coffee. A charac- 
teristic indication for it is found when the 
patient "cannot sleep for thinking." The mind will not rest. 
The mental faculties are more than usually and incessantly active. 
The fact that coffee disagrees with a person when she is well, may 
afford you a clinical hint which will be available in prescribing for 
her when ill. The coffee may be administered in the crude form. 
in the lower, medium, or even the higher potencies, with equally 
good results, as in the case I have cited. In some forms of hys- 



90 LECTURES, CLINICAL AND DIDACTIC, 

terical neuralgia, you may effect a prompt cure with caffeine in 
the third decimal trituration. In one form or another, coffea has 
appeared to me to be very well adapted to many of the nervous 
affections of old people, and of old ladies especially. 

PROCIDENTIA UTERI FROM PERTUSSIS. 

Case . — At the eighth month of pregnancy, Mrs. , aged 32, 

was seized with a violent attack of whooping cough. The parox- 
ysms of coughing were so frequent and severe as to threaten pre- 
mature labor ; but by careful management she was finally brought 
to term without any serious mishap. After delivery she got up 
well, the violence of the cough gradually abating until, at the end 
of two months, it had almost entirely ceased. With the excep- 
tion of a slight cough, and an habitual constipation (which she 
always has while nursing), she felt herself well. At the end of 
the third month, and while taking her usual afternoon drive, she 
took cold, and the consequence was, a recurrence of the whooping- 
cough. The fits returned with their former severity, and she 
" felt as if she should cough herself to pieces." The second even- 
ing after the return of these trying symptoms, while at stool, and 
during a paroxysm of the cough, she suddenly felt something 
escape the vulva. I was summoned, and arrived shortly. The 
womb had been forced entirely out of the pelvis, and was lying 
between the thighs. It was easily reduced by appropriate taxis 
and the proper treatment was instituted. She made a good 
recovery. 

Pertussis is a rare contingent of pregnancy. This case is, there- 
fore, somewhat extraordinary. I have cited it in order to make a 
few clinical points particularly clear to your 
T.w^n^rL^ dia " minds. It illustrates the antagonism of the 

pnragm and perineum. o 

diaphragm and the perineum, the former of 
which, you remember, is the muscular floor of the thorax, and the 
latter of the abdomen, or, more properly, of the pelvis. In con- 
sequence of gestation, and after delivery, the lateral and inferior 
supports of the womb are not always sufficient to retain it in situ. 
The ligaments have been stretched and off duty for so long a 
time that they are lacking in tone and strength. The vaginal and 
muscular column resting on the perineum has been so relaxed and 
distended as to yield it but little support from below. 

This state of things predisposes to downward displacements of 



ON THE DISEASES OF WOMEN. 91 

the womb after delivery. If the patient is upon her feet too early 
and too frequently, if the womb folds upon itself very slowly, 
and its involution is imperfectly accomplished, such mishaps are 
more likely to follow. Constipation in some lying-in women, and 
diarrhoea in others, are predisponents of prolapsus and procidentia 
uteri. 

Among the exciting causes of these particular displacements in 
lying-in women, and in those who have recently been delivered, a 
violent cough is, perhaps, the most serious. 
di?°iaSm a e nr se ° f uterine Hence, we may have prolapsus in a slight or 
extreme degree as a concomitant of pneumonia, 
pleurisy, bronchitis, or whooping cough. The pectoral lesion 
proper has nothing to do with causing the displacement. The 
cough alone is responsible for it. It acts through the spasmodic 
and forcible contractions of the diaphragm, which it necessarily 
induces. And the more violent the coughing fit, the greater the 
danger of this unfortunate result. 

During the fit of whooping cough the convulsive action of the 

diaphragm is sometimes prolonged and painful. In children it is 

very apt to be followed by retching and vomit- 
Labor a predisponent. . . . 

mg, and sometimes by severe and intractable 
tenesmus of the bowel. In the case of my patient, who had just 
been straining at stool, its effect was to overcome the slight resis- 
tance offered by the sphincter vaginse and the perineal muscles, and 
to empty the pelvis of the womb itself. Of course, this accident 
would be much more likely to happen at the second or third month 
after confinement than after the vagina and perineum, as well as 
the uterine ligaments, had recovered their tonicity, and were bet- 
ter able to sustain the womb, and to retain it in its proper place. 
Treatment. — The treatment proper for a case of this kind is 
preventive, postural, and remedial. 

The occurrence of a severe cough during gestation, and espec- 
ially towards its close, should cause you to take especial pains to 
prevent such a sequel to the labor as happened 
in this case. After delivery the patient should 
be kept in the horizontal position for a longer period than usual. 
The binder should be snugly and firmly applied, and she should 
not be allowed to stand upon her feet until three or four weeks 
have elapsed. She should be cautioned against straining at stool. 



92 LECTURES, CLINICAL AND DIDACTIC, 

or in urinating, and counseled to suppress the desire to cough, as 
much as possible. 

Where the womb has really been expelled, the first thing to be 
done is, of course, to replace it. This may be easil}' accomplished 
in recent cases. Place the patient on her back, 
raise the hips and lower the head. Then, hav- 
ing anointed the hand, grasp the tumor firmly, and insinuate it 
gently within the vulva, passing it first in the direction of the 
vaginal axis, and afterwards in that of the pelvic axis proper. 
When in situ, apply a perineal bandage and pad, which should be 
worn for some weeks, even after the patient has left her bed. 
There is no more natural and effectual support, in a case of proci- 
dentia, than this. You can extemporize such a support out of the 
simplest materials. 

The most appropriate and efficient remedies should be given for 
the cough, and every precaution taken to prevent a relapse. This 
is especially important in case of whooping cough, the effects of 
the paroxysm being so disastrous and prejudicial to permanent 
recovery. Cure the cough, and its indirect consequences will 
cease. Stop the convulsive action of the diaphragm, and the uter- 
ine displacement may not return. 



ON THE DISEASES OF WOMEN. 93 



LECTURE V. 



CHLOROSIS. 



Gentlemen : 

I will open my lecture with some remarks upon the following 

Case. — Miss , aged eighteen, complains of a complete loss 

of appetite, and of headache. She is listless, and suffers greatly 
from palpitation of the heart, especially after exercise. At times, 
she has a dull, dragging pain in the cardiac region. The ansemic 
murmur (bruit cle citable} is easily recognized. Until about a year 
ago she felt very well, but since that time these symptoms have 
been steadily increasing in severity. The skin is pale, of a green- 
ish-yellow tint, and almost transparent. Her lips, tongue, and alse 
nasi are almost colorless. The eyelids and features are slightly 
cedematous, particularly after sleeping. The teeth are decayed, 
the finger nails brittle. She has never menstruated, and says that 
her mother and her elder sister were more than nineteen years old 
when their menstrual function was first established. 

In rare instances chlorosis is a congenital affection. A large 

proportion of cases occur in the young and unmarried. Absence 

or suppression of the menses is so frequent and 

Chlorosis and amenorrhoea. ..,"-.. 

almost invariable an accompaniment 01 chloro- 
sis, that some authorities have regarded it as identical in nature 
with amenorrhoea. Others are not decided as to which is cause 
and which effect — whether the chlorosis is the cause or the con- 
sequence of the menstrual derangement. 

We remark in chlorosis a decided impairment of the vegetative 
functions. There is always more or less of headache, anorexia, 

gastric derangement, dyspnoea, fluttering, pal- 
Digestive symptoms. fo . . . ?. J , L . .7 

pitation, timidity, general malaise, constipation, 
and hypochondria. In some cases these symptoms persist for 
years without proper recognition and relief. They are exceedingly 
common among young, delicate girls, especially among those who 
work in shops and factories, and who follow sedentary pursuits, as 



94 LECTURES, CLINICAL AND DIDACTIC, 

seamstresses and school-teachers. Their persistence and the 
accompanying ill health frequently lead physicians to decide that 
such patients are suffering from inflammation of the brain or its 
membranes, ulceration of the stomach, phthisis pulmonalis, organic 
disease of the heart, of the liver, or of some other organ. 

The headache is very prone to take on the form of hemicrania, 

and is not unfrequently mistaken for neuralgia. Sometimes it is 

regularly periodical. It is always paroxysmal, 

Cerebral symptoms. , . n 1 . 

and is greatly aggravated by emotional causes, 
over-anxiety, and too much of mental labor or worry. In rare 
cases it is so severe in degree as to produce delirium, spasms, and 
even mania. And thus it happens that the patient may suffer a 
temporary loss of memory, or she may decline into a state of men- 
tal torpor, and general insensibility. Chorea, hysteria, partial 
paralysis, and epilepsy, are among the possible concomitants and 
sequels of this headache in chlorotic subjects. 

While they are really the least serious, the heart symptoms are 
the most alarming to the patient and her friends. Chlorotic pal- 
pitation, as it is termed, is due to a functional 

Cardiac symptoms. •-iii r> i i t 

change in the rhythm ot the heart s action ; 
this change is of nervous origin, and has no necessary connection 
with organic disease of the heart. It may continue for years 
without inducing any structural changes, or the prolonged func- 
tional disorder may insidiously injure the heart's texture. 

There is a strange relation or sympathy between the generative 
system of the female and the heart. One woman has menstrual 

retention from dysmenorrhcea, and all her suf- 
j£££Z^S$££ ferin g s are referred to the cardiac region. 

Another has menorrhagia, and she complains 
only of similar symptoms. A third, who has chronic ulceration 
of the os uteri, tells the same story. In a fourth, the sole patho- 
logical result of an excess of sexual indulgence is disclosed in the 
same identical symptoms. The same may be true of amenor- 
rhcea, prolapsus, ovaritis, and chlorosis. By physical exploration 
we can detect no difference in the incidental conditions of the 
heart. The whole prsecordial trouble is symptomatic, nor will 
the objective cardiac symptoms enable us to differentiate between 
them. 

In chlorosis the pulse is usually, but not in every case, slower 



ON THE DISEASES OF WOMEN. 95 

and weaker than natural. It may not exceed fifty or fifty-five 
beats in the minute, and is sometimes as low as 
. forty-five or forty-eight. Now and then, how- 
ever, you will encounter a case in which it is considerably quick- 
ened. As a rule, the more marked the anaemia the more frequent 
the pulse, providing, of course, that the impoverished condition 
of the blood is not the result of sudden and excessive haemorrhage. 
In chlorosis, as in hysteria, the pulse has this characteristic, that 
whatever its usual rate of frequency, no matter what the condi- 
tion of the patient, or the circumstances in which she may be 
placed, that rate is but little, if at all, changed thereby. 

The ansemic murmur, (bruit de diable^) which, in most cases of 
chlorosis, may be heard over the precordial region, but more dis- 
tinctly along the course of the great vessels, as 

The anaemic murmur. , • i -i p i , • • • i 

the carotid and iemoral arteries, is a curious and 
suggestive symptom. Some authorities believe it to be caused by 
an impoverished condition of the blood, in which there is a defi- 
ciency in the proportion of red corpuscles. Others ascribe it to a 
diminution in the volume of the blood contained in the vessels. 
It occurs in anaemia as well as in chlorosis. 

There is not unfrequently a total loss of appetite. The patient 
may subsist for months upon an incredibly small quantity of food. 

In other cases the most unheard-of caprices are 

The appetite. 

likely to be indulged. She craves such outre 
articles as chalk, plaster, bits of clay, of coal, or of slate-pencil, 
cinders, sand, magnesia, grains of coffee, and vinegar. A fre- 
quent peculiarity of the appetite is a total disrelish for, and dislike 
of, every variety of animal food. One of my chlorotic patients 
had not tasted a mouthful of any kind of meat for more than ten 
years. In some the appetite is fitful. They will fast for a long 
time, and then eat excessively. Generally, they do not anticipate 
or enjoy their meals, but " go through the motion " of eating at 
stated periods, simply because it is expected of them in the fam- 
ily and in society. 

In consequence of this impairment of the digestive functions, 
a train of symptoms is sure to follow. The bowels become in- 

veterately constipated, or there may be alterna- 

Incidental symptoms. . 

tions or constipation and diarrhoea. 1 he breath 
is sometimes disagreeable, or even foetid. In a few cases observed 



06 LECTURES, CLINICAL AND DIDACTIC, 

by Marshal Hall, it had the odor of new milk. In very rare and 
extreme cases hsematemesis or malsena may ensue. Sometimes 
there is obstinate and persistent ulceration of the stomach, with 
intractable vomiting of ingesta. The cellular and muscular tis- 
sues become flabby. There is general and progressive emaciation. 
She becomes bed-ridden, and is believed to have passed into a 
hopeless decline. A species of dropsy, either general or local, 
may supervene. Some patients with chlorosis suffer great torture 
from gastralgia. In others there may be successive attacks of 
gastro-enteritis. Organic lesions of the liver and spleen are fre- 
quent concomitants of chlorosis, especially in the west and south- 
west, and in all malarial regions. 

It is unusual for this disease to exist without more or less mens- 
trual derangement. The most ordinary complication of this kind 
is with amenorrhea. The chlorosis may set in 
in^chbroSs 1 irregularItIes before the menses have appeared, at puberty, 
and they may fail altogether. Or there may be 
an incidental and prolonged arrest of the flow in those who have 
menstruated before. In either case, the menses do not appear for 
months, and perhaps for years. The suppression may date from 
the commencement of the chlorosis, but most frequently it follows 
in the train of other symptoms. The chlorosis is very apt to come 
on stealthily and insidiously, so much so that neither the patient 
nor her family remark anything wrong with her health until the 
disease is pretty well developed. She may have complained for a 
considerable period of symptoms of which I have spoken, and in 
addition have noticed that her catamenial discharges were less free 
than natural, but it is not, perhaps, until the flow has ceased alto- 
gether that any .alarm is excited, or counsel desired in her case. 
It has frequently happened that the co-existence of amenorrhoea 
and gastric derangement has given rise to suspicions of pregnancy ; 
while in other cases, the arrest of the menses with troublesome 
chest symptoms has aroused suspicions of incipient tuberculosis. 
Although she is eighteen years of age, this woman has never 
menstruated. But in her case there is a family or hereditary idio- 
syncrasy which may explain this fact. Her 

Hereditary amenorrhoea. ^ 

mother and sister were nineteen years old be- 
fore the menses appeared. We cannot, therefore, charge the non- 
appearance of the flow to the chlorosis, or vice versa. From which 



OX THE DISEASES OF WOMEN. 97 

you will infer that although they may and do frequently co-exist, 
these disorders have no necessary relation with each other. 

You will sometimes meet with chlorosis in a patient who is 
subject to dysmenorrhcea. In such cases, the incidental hysteri- 
cal symptoms are more pronounced and per- 
^cworosisanddysmenor- s i s tent. They are very troublesome and diffi- 
cult of cure. The menstrual flow often be- 
comes so scanty as to increase the difficulty by its retention, and 
we may thus have a case of painful menstruation resolving itself 
more and more into one of entire suppression. Or the dysmenor- 
rhea may develop into menorrhagia, which will further compli- 
cate the chlorosis. 

Chlorosis is also incident to those states in which menstruation 
is physiologically suspended. It may occur 

Chlorosis in pregnancy, etc. ... . .. .. _ _ 

during pregnancy, m child-bed, during lacta- 
tion, or after the grand climacteric. 

The peculiar discoloration of the skin, which is very marked 

in this case, is pathognomonic. In mild and recent attacks it is 

of a pale greenish tint. Hence the popular 

Discoloration of the skin. . 

name, "green sickness. lhe lips, alas nasi, 
the gums, and the tongue, lose their vermillion hue. The skin 
is sometimes of a yellowish cast. (Sauvage called chlorosis 
"white jaundice.") In later stages of the disease, and in very 
had cases, the discoloration is more marked. The skin becomes 
of a waxy, dull leaden, slate-color, sallow, or dirty-white hue, 
and there are dark lines beneath the eyes, and at the angles of 
the mouth. The white of the eye has a peculiar pearly, trans- 
lucent appearance. The face becomes tumid, and the eyelids, 
especially the upper one, puffy and oedematous. The general 
surface of the body appears dry, bloodless and opaque. The hands 
are shriveled, the nails split, brittle and broken. 

Patients with this disease are averse to exercise, and to society. 
They become listless, and sometimes pass into a state of pseudo- 
narcotism ; or they are low-spirited, and look 

The mental state. _. _ . 

upon hie and the iuture with the most gloomy 
forebodings. They are disposed to melancholv. They lose 
interest in their studies, permit their accomplishments to grow 
rusty from disuse, and, in brief, are really wretched. 

Etiology. — The causes of chlorosis are predisposing and excit- 
7 



98 LECTURES, CLINICAL AND DIDACTIC, 



o 

Chlorosis and scrofulosis. 



Among the former, the most prominent is the lymphatic 
temperament. It is extremely rare to meet 
with it in any other class of subjects. This 
predisposition is strengthened by a tendency to scrofula. In 
these persons the blood-making function is liable to such dis- 
order as results in a deterioration of the quality of that fluid. 
Hence the relative diminution of the red corpuscles, and the pro- 
portionate increase in the watery part of the blood, which are 
almost always present in chlorosis. This predisposition is fostered 
by whatever hygienic influences may tend to lower the standard 
of health, and to vitiate the process of sanguification. These 
causes are usually classed as exciting ; but they are only remotely 
so. They include an exclusive diet of indigestible, inappropriate 
or unwholesome food, confinement in damp, shady, illy-ventilated 
apartments, deficient exercise and clothing, unrequited affection, 
nostalgia, ennui, chagrin, jealousy, fright, sexual excitement, and 
uterine and ovarian disorders. 

Most authors will tell you that chlorosis arises from " a disease 
of the blood," a phrase which is utterly destitute of meaning. 
It is true that in many cases the proportion of 
s . Biood-changes in chioro- ^ e rec [ globules is deficient : but unless it be 
traceable to a loss of blood by haemorrhage, 
that is a symptom merely. In anaemia from haemorrhage of any 
kind, the poverty of the blood is accidental, and due to an actual 
loss or withdrawal of the colored corpuscles. In chlorosis, the 
change in the composition of the blood has been gradual, is the 
woik of disease that has implicated and impaired the process by 
which the blood itself is made. In the one case it is a chance 
effect ; in the other a natural and necessary consequence of 
diseased action. 

I have already explained the physiology of hamiatogenesis.* 

You are familiar with the function of the lymphatic glands and 

their duties in this relation. Without their 

Hsematogenesis. . 

aid, the blood could not be manufactured. It 
is a peculiar predisposition to disease in them which constitutes 
the chlorotic diathesis. But these glands cannot operate inde- 
pendently of the nervous system, any more than the liver or the 
pancreas. And so we must go back of them for the prime cause 
of the disorder. 

* See Lecture II, pp. 41-2, of this volume. 



ON THE DISEASES OF WOMEN. 99 

It is "begging the question" to refer the essential pathology of 
chlorosis to an impoverished condition of the blood. That fluid 

may contain seven-tenths, or even nine-tenths 
ro5s h rnc5ema?. ia in chl °~ serum, as found in Jolly's analysis of the blood 

of chlorotic subjects, but it will not suffice to 
declare that all the symptoms in this disease are due to, and 
depend upon, this condition alone. Nor does the relative loss of 
the red globules represent the disease. The special pathology 
and etiology of chlorosis are not to be found in the hydremia, 
spansemia, or the chloro-ansemia, which in most cases are attend- 
ant upon it. For occasional well-marked cases of this disease are 
certainly met with, in which there is no manifest change in the 
composition of the blood. 

Numerous reasons have been adduced for a belief in the ner- 
vous origin of chlorosis. Thus Eisenmann* assigns the following : 

"(a) In certain cases Becquerel and Rodier 

The nervous theory. _ .1111 

tailed to detect any changes m the blood. (0) 
Chlorosis is much more frequent in females than in males, and it 
is a well-known fact that the nervous system predominates in the 
former, (c) The incipient symptoms of chlorosis, those which 
anticipate any change in the blood are nervous, and those nervous 
symptoms continue through the whole course of the disease, (c?) 
Chlorosis yields to those remedies which are known to act favor- 
ably in affections of the spinal cord, as morphia, strychnia," etc. 

To these we may add that many attacks occur in those who are 
predisposed to chlorosis, in consequence of fright, the exercise of 
strong mental and moral emotions, sexual excitement, masturba- 
tion, and the nervous tension incident to city life and society 
among the better classes. Dr. Clotar Miiller bases his assump- 
tion of the nervous origin of chlorosis on (a) " the great influence 
which mental emotions and certain depressions of the nervous 
system exert upon the origin and development of chlorosis ; and 
(5) the powerful curative influence of remedies acting directly 
upon the nervous system, and manifesting an influence corres- 
ponding homoeopathically to the depression and general prostra- 
tion of vital power peculiar to this disease."! 

The same author says : " If I may venture to draw a conclusion 
from my own observations, I should assume as most probable that 

* Bulletin de Therapeutic, Sept. 30, 1S59. 

f Vide North Am. Horn. Quarterly, Vol. VII, p. 158. 



100 LECTURES, CLINICAL AND DIDACTIC, 

chlorosis is originally an affection of the spinal and ganglionic 
systems of nerves, having a character of weakness and exhaustion 
combined with erethism and excessive excitability." Becquerel 
and Roclier confirm this view : " For us, as for some other authors, 
chlorosis is a disease which has its beginning and its seat, its 
point of departure primarily, in the nervous system, giving rise 
consecutively to disorders of digestion, of menstruation, and of 
the circulation. If this definition is correct, the change in the 
blood in chlorosis is not a constant and capital fact, but a second- 
ary, incidental phenomenon, which is not absolutely indispensable 
to the disease."* 

Gabalda says emphatically, " We regard this disease as a per- 
fectly distinct neurosis." M. Jolly and Dr. Tilt insist that 
chlorosis is a neuralgic affection of the ganglionic system. Dr. 
H. Jones, that " in many cases, occurring among the poorer classes 
in London, the action of malarious influences upon the ganglionic 
system is the first link in the chain of causation." 

Upon this theory, which is so well supported by facts and by 
medical authority, we are able to explain the insidious and pecul- 
iar character of this complaint Its seat is in the nervous system. 
Back of all the symptoms disclosed by the solids and fluids, the 
cause is at work to undermine the general health. And thus it 
happens that in confirmed chlorosis " there appears to be not a 
system, an organ, a texture, or even a fluid, in the animal economy, 
which does not suffer." 

I have already said that the menstrual disorders incident to 
chlorosis are generally considered as the cause, and not the con- 
sequence thereof. The argument against this 
en?r h rhTa, iS et?. recedes am ~ hypothesis is short and simple. In a majority 
of cases the manifest signs of chlorosis appear 
before there is any derangement of the monthly periods. In some 
instances the menstrual function escapes all implication, and the 
patient has chlorosis without any catamenial irregularity whatever. 

Now, if the non-appearance of the flow, or its suppression, or 

even its excess, were the cause of this disease, 

sy™l?oTatl* omplic * t[ons one or the other should always precede the 

pallor of the skin, and the nervous, circulatory, 

and digestive symptoms of chlorosis ; this affection could never 

* Traite de Chemie Pathologique appliquee a la Medicine Pratique. 1864 ; p. 155. 



ON THE DISEASES OF WOMEN. 101 

exist in one who menstruates regularly ; nor could it ever occur, 
as it really does, in the male subject. We therefore conclude 
that the menstrual complications incident to chlorosis are symp- 
tomatic, and not idiopathic. The real disease is the chlorosis, 
and not the amenorrhcea, the dysmenorrhea, or the menorrhagia. 
It is said that in the West Indies many male negroes formerly 
sickened and died of a disease which, in all of its principle 
features, was identical with chlorosis. 

With characteristic originality, Prof. Meigs styled chlorosis an 
" endangial disorder." He referred all the symptoms, but more 
especially the changes in the composition of the blood, to a path- 
ological state of the endangium, or lining membrane of the circu- 
latory vessels. 

Dr. Von Maack* holds that, in chlorosis, it is impossible for the 
iron of the food to be changed into hsematin and fixed. And this 
because the saccharine function of the liver is either disordered 
or arrested. But this must suffice for the etiology of chlorosis. 

Diagnosis, — You will not be very likely to confound chlorosis 
with jaundice. The pearly look of the white 

Chlorosis and jaundice. . _ 

oi the eye m the former disease, and its yellow 
cast in the latter, will enable you to differentiate between them. 

I have drawn the following table, which may help you to diag- 
nosticate chlorosis from anaemia : 

CHLOROSIS. ANEMIA. 

1. Is an idiopathic affection. I. Is an accident, or sequel of other dis- 

eases. 

2. Is not caused by the loss of blood, or 2. Is frequently caused by haemorrhage, 
other debilitating discharges. suppuration, leucorrhcea, diarrhoea, 

colliquative sweats, etc. 

3. May result suddenly from mental 3. Never does, 
causes alone. 

4. The mental and nervous symptoms are 4. Not so in anaemia, 
especially prominent. 

5. The nervous symptoms initiate the 5. The opposite occurs in anaemia, 
attack. 

6. Fugitive neuralgic pains in the head, 6. These pains are lacking, 
the spine, the stomach, the chest, and 

especially in the side, are almost inva- 
riably present. 

7. May be accompanied or followed by 7. These complications and sequelae are 
hysterical spasms, chorea, paralysis, or not incident to this affection, 
epilepsy. 

* L'Union Medicale, February, 1859. 



102 LECTURES, CLINICAL AND DIDACTIC, 

CHLOROSIS. ANAEMIA. 

8. The skin is of a greenish, or greenish- 8. The skin is blanched, palid, puffy, and 
yellow tint. doughy. 

9. Haemorrhages are not very frequent. 9. Haemorrhages are very frequent. 

10. Is very rare in male subjects. 10. Affects the sexes indiscriminately. 

11. Rarely happens in those who are un- 11. May occur at any age. 
der twelve or over thirty years old. 

12. Is limited to women of lymphatic 12. May happen to women or men of any 
temperament. temperament. 

13. Is very liable to be accompanied by 13. Is more likely to be accompanied by 
suppression or retention of the men- too frequent and copious menstrua- 
ses. tion. 

14. May exist and run its course without 14. Is always characterized by an impov- 
any perceptible change in the compo- erishment of the blood. 

sition of the blood. 

15. The degree of change in the blood 15. The impoverishment of the blood is 
bears no necessary relation to the in direct ratio with the degree of func- 
severity of the disease. tional disorder. 

16. Is most common among the better 16. Is most common among the poorer 
classes of society. classes. 

Although these symptoms are sufficiently distinctive, it some- 
times happens that a diagnosis between these affections is 
extremely difficult, if not altogether impossible. There are, 
doubtless, exceptional cases, in which they co-exist in the same 
patient. 

Prognosis. — In the milder forms, and under proper manage- 
ment, chlorosis is curable. The chief danger is from incidental 
organic diseases, the most serious of which are 
diSas n e ger from incidental cardiac and pulmonary affections, myelitis, 
tuberculosis, dropsy, paralysis, epilepsy, and 
repeated haemorrhages. The disease is of a lingering, tedious 
nature, and patients get well or worse very slowly, But now and 
then one who has been ill with this disease for a long time dies 
suddenly without any premonition. For this reason, your prog- 
nosis should be guarded. 

It is a favorable sign if, under treatment, the appetite and 
spirits improve, and also if the menstrual irregularity is corrected 
without forcible measures. Relapses are frequent. 

Treatment. — After this analysis of the disease in question, you 
are prepared to appreciate the difficulties in the way of its most 
appropriate and successful treatment. Its Protean phases and 
multiform complications sometimes embarrass the practitioner 



ON THE DISEASES OF WOMEN. 103 

exceedingly. The rule, however, holds, that the more carefully 
the remedy is chosen, providing other very necessary conditions 
are complied with, the more certain and satisfactory is the result. 

In general, you should give especial prominence to remedies 
which are suited to derangements of the nervous functions, or of 
the circulation, or of digestion, or of menstrua- 
stSr edies for general tion. These are cardinal points in the special 
therapeutics of chlorosis. In most cases, the 
characteristic indications are discoverable in them. In one per- 
son the nervous symptoms may predominate ; in another, the 
digestive ; in a third, the sexual, and so on. Or, if they are min- 
gled, try to learn the order of their sequence, their cause or 
causes, and what constitutional or accidental agency serves to 
perpetuate the mischief. 

You may often find the proper remedy by selecting one that is 
appropriate to the mental or emotional condition which induced 
the attack. Our works on materia medica teach 
caTs r e atmentforemotional y° u wnat these remedies are. Most prominent 
among them is ignatia. After this, there are 
belladonna, hyoscyamus, coffea, opium, aconite, and some others. 
In selecting from this, and a much larger catalogue, the indica- 
tions are very similar to those which call for certain remedies in 
hysteria. 

Calcarea carbonica, sepia, sulphur, natrum muriaticum, graph- 
ites, ferrum, phosphorus, plumbum, and similar remedies, are 
often appropriate for the chlorotic cachexia, 
rodcTa e c d hexi[° r the cHo * an d- i n chronic cases may sometimes be given 
temporarily with good effect, in lieu of other 
medicines. The first two are especially useful in the menstrual 
irregularities incident to chlorosis. The same is true of cyclamen 
and pulsatilla. Other remedies sometimes employed are kali carb., 
arsenicum, lycopodium, conium, nux vomica, china, chamomilla, 
helonine, and senecin. Indeed, as in hysteria, almost any remedy 
in the whole range of the materia medica may be called for. It 
would be a work of supererogation, as inappropriate as a pater- 
noster, for me to detail all the symptoms which might indicate 
them in this connection.* 

Upon the theory that chlorosis and anaemia are identical, and 

* For particulars see N. American Horn. Quarterly, Vol. VII, p. 152, et seq. 



104 LECTURES, CLINICAL AND DIDACTIC, 

that both affections are due to a deficiency of iron in the blood,, 
iron is regarded by many physicians as a spe- 

Iron in chlorosis. . ~ , , . Tl . , . . ,, 

cmc in chlorosis. It is almost as universally 
given in this disease as quinine in intermittent fever, or mercury 
in syphilis. But, for the best of reasons, it frequently fails to 
cure. In order to be useful, it should be prescribed upon patho- 
genetic indications, and in such form and quantity as to be avail- 
able. When there are only about thirty grains of iron in the 
whole mass of blood contained in the body, it surely is irrational 
to attempt to supply any deficiency thereof by thrusting large 
quantities of the crude metal, or any of its salts, into the stomach. 
Iron is not appropriate to those cases of chlorosis which are of 
nervous origin, or in which, from the onset of the disease, the 
nervous symptoms have been especially prominent. In anaemia 
proper it is more generally useful. 

In many cases of chlorosis there is, however a preparation of 
iron in which I have great confidence. This is the citrate of iron 

and strychnia, a salt which came into use some 
strycES ° f iron and years ago. I give it empirically in the third 

decimal trituration. In my experience nothing 
is so well adapted to control the whole train of symptoms in most 
cases, although it is by no means an invariable specific. It seems 
to combine the good qualities of iron with those which belong to 
the strychnia group. It will accomplish more than ferrum metal- 
licum, ignatia, nux, or strychnia, when given separately. I could 
detail several cases of this disease cured with this remedy alone. 
In this compound form it certainly merits a proving. 

For an interesting paper on chlorosis arising from mental shock, 
I refer you to Dr. Hammond's recent report of several cases of 
this kind cured with arsenic and strychnia.* 

Much harm is sometimes done by attempting to force the men- 
strual flow. You should be careful to avoid this, remembering 

that the menses will appear as soon as the gen- 

Wrong to force the menses. *- ^ m *f 

eral health warrants and favors it. Relieve 
other and more urgent symptoms, restore the physiological equi- 
librium, and this function will probably resume its accustomed 
order. There is good reason for believing that the non-appear- 
ance of the menses in many cases of chlorosis is a conservative 

* Quarterly Journal of Psychological Medicine, etc., Vol. III., p. 417. 



ON THE DISEASES OF WOMEN. 105 

precaution, designed by nature to economize the patient's 
strength. 

An exception to the rule just specified is found in those cases 

of spasmodic dysmenorrhcea, which are incident to chlorosis. 

Here the most sensible and successful plan of 

Spasmodic dysmenorrhcea. . 

treatment is to address our remedial measures 
to the cure of the stricture of the uterine cervix, upon which the 
nervous symptoms depend for a local cause. We may give bella- 
donna, gelsemiuum, caulophyllin, or some analogous remedy. 
The warm sitz-bath, or vaginal injections of warm water, may 
facilitate the flow, and relieve the suffering and the remote ner- 
vous symptoms at the same time. But if the spasm of .the cervix 
is particularly obstinate, I know of nothing to compare with the 
careful and appropriate use of the sponge-tent. 

Much relief may sometimes be afforded by domestic adjuvants. 

In case of spinal irritation and tenderness, the back maybe sponged 

once daily with salt and water. Friction along 

Adjuvants. . p 

the spine is sometimes very useiul. lor the 
relief of local neuralgic pain, in the side and chest especially, the 
part may be covered with a layer of cotton batting, oiled silk or 
flannel. If the pain is very acute, dry heat will suffice. If it is 
rheumatic, the local use of hamamelis may be prescribed. 

The diet should be selected with great care. It should consist 
of digestible and nutritious articles, both animal and vegetable. 

If the patient has a distaste for meat, she may 

The diet. .,,.,,.. . , 

cultivate an appetite tor it, by beginning with 
salt meat of some kind, as, for example, cod-fish, mackerel or her- 
ring, dried beef, lean ham, and the like. Or sea-food, as oysters 
or other shell-fish, may be taken. Eggs or milk prepared in vari- 
ous ways, may tempt the appetite. Bread from unbolted flour, 
animal broths, chocolate or malt liquors, may be chosen. She 
should not be ordered to ride or to exercise upon an empty stomach. 
Moderate exercise in the open air is indispensable. Riding, on 
horseback or otherwise, is preferable to walking or performing 

manual labor. And when your chlorotic pa- 

Exercise and travel. . n . . . , . , 

tients go tor an airing m their carnage, he sure 
they have the light as freely as they have the air. These hot- 
house productions need it as much as the pale plants that have 
grown in the cellar. Boating, billiards, croquet and calisthenics 



106 LECTURES, CLINICAL AND DIDACTIC, 

may be very useful. But best of all is a change of scene and sur- 
roundings. If to these can be added the health-giving influences 
of cheerful society, so much the better. These hygienic means 
will frequently accomplish more than our best chosen remedies. 
Sea-bathing has its advocates, and mineral waters, especially those 
which are chalybeate, are strongly recommended. 

Whatever the cause may have been, it should be removed, and 
the utmost pains taken to keep the patient from under the do- 
minion of all perturbing influences. Marriage is sometimes salu- 
tary, but is of questionable utility, excepting where the attack 
has resulted from disappointed love. 

Miss will take a small powder of the citrate of iron and 

strychnia, 3rd dec. trituration, twice daily, with out-door exercise 
and a generous diet.* 

AAIEXORRHCEA WITH SUPRA-ORBITAL NEURALGIA. 

Case. — Mrs. R , aged 36, with light hair, blue eyes, and 

mild disposition, complains of a peculiar form of neuralgia associ- 
ated with the return of menstruation. The menses are tardy ; 
sometimes delayed one, two, or even three days. Their appear- 
ance is invariably preceded by a violent neuralgic pain, which is 
located over the left eye, along the superciliary ridge. This suffer- 
ing usually begins when the flow should commence, and continues 
with increasing severity until menstruation sets in, after which it 
gradually subsides. In the interval her health is excellent. She 
has neA r er had any other form of neuralgia, but has been subject 
to this for ten years past. It has never been located over the 
right eye, or in any other than its present seat. She " expects to 
be sick " three or four days hence. 

This case is an anomalous one. It is by no means rare to hear 
women complain of neuralgia which is most troublesome " at the 

month." Sometimes it affects the head, the 
neIr a alSi! sof menstrual face, the teeth, or the ears. There are those 

who have occasional attacks of angina pectoris 
at this period. Ovarian and mammary neuralgia are frequent 

*At the end of one month, the menses made their first appearance. She had 
much pain, with scanty flow. The second period was regular, the flow free enough, 
with little relative suffering. The headache and cardiac symptoms had entirely disap- 
peared ; the skin became natural ; the lips and cheeks had resumed their proper color. 
-She took no other remedy. 



OX THE DISEASES OF WOMEN. 107 

accompaniments of menstruation. Incidental, shifting local pains 
often torment women whose courses are due but are somewhat 
delayed. But a circumscribed neuralgia of this sort, in this par- 
ticular locality, recurring with the regularity of an ague paroxysm, 
in immediate relation with the menses, and subsiding as soon as 
they have commenced, is by no means common. 

A strange peculiarity contingent on all these cases of men- 
strual neuralgia, is that the pain is more 

Local peculiarity. _., . . x 

likely to be seated in the left than m the 
right side of the body. 

Treatment. — These pains are reflex. The cause that produces 

them is a temporary retention of the menses. Remove this cause, 

and the suffering is at an end. This indication 

Local treatment. . 

may be met, temporarily at least, by a yariety 
of domestic expedients. A drink of gin, a warm sitz-bath, the 
application of a bag of hot salt to the hypogastrium, the operation 
of a carthartic or an enema, chloroform, or opium, may promote 
the menstrual flow and arrest the pain. But these expedients are 
only palliative and transient in their effect. They will exert no 
influence over the function at the next period. In anticipation 
of the menses the neuralgia will return again. 

In order to effect a radical cure thereof, we must look to the 
seat and character of the pain, its particular relation to the men- 
strual nisus, whether it comes on, or is worse 
before, during, or after the flow, and to like 
symptoms, for especial indication for our remedies. I have never 
seen but one well-marked case of this kind before. It was the 
exact counterpart of this. I gave that woman pulsatilla 3rd. 
The flow commenced almost immediately ; the neuralgia van- 
ished ; and although five years have elapsed, it has never returned. 
Mrs. R. will take the same remedy three times daily, until the 
menses appear, and I prophesy that she will be free from this 
unwelcome neuralgia in the future. 

HYSTERIA AT THE CLIMACTERIC. 

Case. — Mrs. S , a strong, healthy-looking woman of 50, 

relates the following history : She was taken ill while pregnant 
with her sixth and last child fourteen years ago. This illness she 
attributes to neglect and unkind treatment on the part of her hus- 



108 LECTURES, CLINICAL AND DIDACTIC, 

band. Despite much trouble, suffering and anxiety, she went to 
term, and her child is still living. Her chief symptoms were a 
feeling as if she were dying, with great prostration, sinking, chok- 
ing at the throat, and partial unconsciousness. She would weep 
and sob for hours together, and her gloomy feelings could not be 
dissipated. These attacks came irregularly, but increased in 
severity toward the close of gestation. 

Two years later an eruption resembling " salt rheum " made its 
appearance on the right arm, above the elbow, and on the same 
side of the neck. The cropping out of this eruption, which is 
worse in cold weather, was followed by manifest relief of the ner- 
vous symptoms. She soon remarked that when it was out most 
freely, she felt best in other respects, and vice versa. This alter- 
nation has continued for twelve years. Whenever the eruption 
disappears, the nervous symptoms are very distressing. 

Menstruation continued regularly until four years ago, the 
patient being at that time forty-six years old. It then began to 
be irregular, sometimes being absent for two, three, or even four 
months, and when it returned, it was liable to be profuse and long- 
continued. Twice she went only two weeks between her periods. 
Once, as they did not return from October to the following July, 
she supposed that they had entirely ceased. 

I have brought this patient before you to illustrate the possible 
relation between a cutaneous eruption and the existence of hys- 
terical symptoms. For twelve years this erup- 

Skin disease and hysteria. . 

tion has alternated with intractable nervous 
symptoms, more alarming than serious. She has been questioned 
very thoroughly, but we cannot learn that she ever had any erup- 
tion which had been repelled prior to the date of her present ill- 
ness. Nevertheless, the evident relation between the disease of the 
skin and the other symptoms complained of will not be doubted. 

Repelled eruptions are, in general, more likely to produce some 
structural disorder of the mucous membranes than to give rise to 
functional or organic lesions of the nervous system. But instances 
are not wanting in which serious neuroses, as, for example, insan- 
ity, epilepsy, paralysis, neuralgia, have been due to this cause. 
And so, also, with hysteria. I have seen the most obstinate cases 
refuse to yield to the best affiliated remedies, because they origin- 
ated in the repercussion of some apparently trifling eruption. If 
you will take this clinical hint at its proper value, it may be of 
great service to you by and by. These cases are exceptional, it 



ON THE DISEASES OF WOMEN. 109 

is true, but such a one may be the very first on the list of your 
private patients. 

The menstrual irregularity in this case is referable to the critical 
period through which the patient has been passing during the 
last four years. 

Treatment. — We should, so far as is possible, ascertain the 
especial nature of the eruption which has caused, or is so nearly 
related to, the disorder for which we are to 
ma h SSe f th h e e remSy n P rescr i De - I s it vesicular, papular, pustular, 
or squamous ? Has it always preserved the 
same character ? Does it itch, or burn, or what are its peculiar 
sensations ? What accidental circumstance is likely to bring it 
out, or aggravate it ? • These and similar inquiries may influence 
the choice of a remedy, especially in chronic cases. The key to 
the cure may be found through them. 

In this case the eruption was originally vesicular. Each time 
it reappears a crop of vesicles forms. They soon break and dis- 
charge, and the serum dries and forms a yellowish crust. This is 
followed by slight itching, especially when the part is exposed to 
the air. 

These symptoms indicate rhus tox., and it alone may be suffi- 
cient for the cure, not only of the eruption, but of the incidental 
affection also. I prefer the thirtieth attenuation of this remedy 
for chronic cases. In exceptional cases, it answers very well to 
alternate two potencies of this remedy, as, for example, the third 
and the thirtieth. If the rhus fails, we may give sulphur in a 
similar manner. 

Mrs. S. will take a dose of the rhus tox. 30th, every morning 
and night, and report in two weeks. 8he must be careful to avoid 
pastry, spices, fats and indigestible food of all kinds. And also 
to forbear applying any wash or ointment that might repel this 
eruption and increase the difficulty. 



110 LECTURES, CLINICAL AND DIDACTIC, 



LECTURE VI. 

ovaritis. 

Gentlemen : 

Inflammation of the ovaries has been designated in medicine as 
ovaritis, oophoritis, oaritis, ovarite, and ovarian folliculitis. There 
are two excellent reasons why you should study the medical 
history of this affection most carefully. In the first place, the 
disease occurs more frequently than is generally supposed ; and 
in the second, our literature is lamentably deficient in respect to 
its pathology and treatment. 

Ovaritis may be acute or sub-acute. Some authors speak of a 

chronic variety, but this is included in the sub-acute, which is the 

more common form of the complaint. Indeed 

freqient ub " acuteformmost since tne y ^ eT onl J in severity and duration, 
one description must answer for all. Most 
authorities are agreed that the left ovary is more frequently 
inflamed than the right one. Out of forty cases collected by M. 
Chereau, the affection was double in four cases, seated in the right 
ovary in eleven, and in twenty-five cases in the left one. Tilt 
found the right ovary inflamed in but five out of seventeen cases. 
M. Tanchou suggests that the nearness of the left ' ovary to the 
rectum, and the mechanical pressure of fsecal matters upon it, 
may account for its greater liability to inflammation. 

Causes. — Ovaritis is rarely an idiopathic affection. It is liable 

to occur immediately before, during, or immediately subsequent 

_ .to the appearance of the catamenia. In many 

Generally symptomatic. . 

cases, every return of the menstrual period is 
characterized by marked symptoms of ovarian irritation and 
inflammation. The ovaries bear much the same relation to the 
uterus, that the Malpighian tufts do to the tubes of Ferrein and 
Bellini in the kidneys. Bearing in mind this intimate functional 
relation, you will readily perceive that amenorrhea, or retention 



ON THE DISEASES OF WOMEN. Ill 

of the menses, from occlusion of the vagina, by an imperforate 
hymen or os, or atresia of the vagina, or of the uterine cervix, 
would be likely to induce congestion of the ovaries, as well as of 
the uterus and Fallopian tubes. The repletion occasioned by the 
non-exit of the menses might be harmful in various ways, but the 
most painful sy mptoms incident thereto would be those of ovarian 
inflammation. 

A sudden suppression of the menstrual flow, as from cold, or 
coitus, has sometimes caused a severe attack of ovaritis. It may 
be due to spasmodic, obstructive or mechanical 
rh2r rkis fr ° m dysmen ° r " dysmenorrhea, arising from partial obliteration 
of the uterine cervix. It is a frequent conse- 
quence and complication of membraneous dysmenorrhea ; and 
Drs. Rigby, Simpson, and others treat of a variety of painful 
menstruation under the title of Ovarian Dysmenorrhcea. If the 
monthly return is characterized by very considerable suffering, 
neuralgic headache, fugitive and erratic pains, and hysterical 
symptoms, one may suspect that the focal point of the disorder 
is in the ovary. 

There are perhaps few examples of menorrhagia of long stand- 
ing that are not dependent upon or associated with ovaritis. 

A frequent cause of the disease under consideration is the 

improper and harmful use of emmenagogues, which are given 

with a view to relieve menstrual suppression, 

From medical and me- or to i nc [ uce abortion. The resort to mechani- 

chanical causes. 

cal expedients for the same purpose may pro- 
duce a like result. These villainous appliances all act as irritants 
to the delicate structure of the ovary, tending to derange its 
innervation, circulation and nutrition, and thus, directly or 
indirectly, to induce the inflammatory process. Inordinate 
sexual indulgence, especially after prolonged or unusual abstin- 
ence, may cause ovaritis. I have met with several examples of 
this kind in women whose husbands had but just returned home 
after a long absence. Ungratified sexual desire, in those who 
are of amorous disposition, may likewise cause ovaritis. Some 
most painful attacks, due to this cause, are met with in young 
widows. The same result has been witnessed in prostitutes 
when placed in confinement. The employment of unnatural 
means for the gratification of the sexual passions ; nymphomania ; 



112 LECTURES, CLINICAL AND DIDACTIC, 

gonorrhoea ; or Menorrhagia in the female ; a too forcible coitus, 
as in rape ; falls or blows upon the iliac region ; the use of 
astringent vaginal injections, causing the sudden suppression of 
leucorrhoeal, or a hsemorrhagic discharge ; the employment of 
escharotics in ulceration of the os uteri ; the extension of endo- 
metritis through the oviduct to the ovary ; retroversion of the 
womb, and constipation, especially at the menstrual period ; 
sudden exposure to cold, and check to perspiration ; emotional 
causes, as the reading of novels by those who are young and of 
sedentary habits ; unrequited affection ; the abuse of aphrodisiacs 
and alcoholic liquors, are among the more frequent and ordinary 
causes of ovaritis. Scanzoni reports having observed many cases 
in which this disease was developed in consequence of an inflam- 
mation of a portion of the intestinal canal, and especially of the 
rectum. I have known it result from a sudden and intentional 
suppression of milk in a mother who had been sucking her 
child. 

The intimate relation existing between the functions of the 

mammary glands and the ovaries is significant of ovarian lesions 

incident to the puerperal state. If the lacteal 

Epidemic ovaritis. , . 

secretion does not appear at the proper time, 
the ovary is very liable to become irritated, and even inflamed. 
This inflammation extends by continuity of surface, to the peri- 
toneum. Hence arises a common sporadic and insidious form of 
puerperal peritonitis. In 1746 an epidemic of this form of puer- 
peral fever prevailed at the Hotel Dieu, in Paris, and another in 
Vienna in 1819. Of fifty-six females who had died of puerperal 
fever, Dr. Robert Lee found that in thirty-two cases the ovaries 
were red, swollen and softened ; and in two hundred and twenty- 
two cases of the same fever M. Tonelle found evidences of 
ovaritis in fifty-eight. _ Kiwisch remarked that, as contingent 
upon lying-in, ovaritis occurs generally in groups of cases, an 
observation that corresponds with the idea advanced by certain 
authorities, that it is sometimes epidemic. Kiwisch has often 
"made from ten to twenty consecutive autopsies without meeting 
with any considerable inflammation of the ovaries, after which 
the disease was observed, in more or less considerable develop- 
ment, in from six to ten individuals consecutively." 

Traumatic causes, incident to labor, sometimes give rise to 



ON THE DISEASES OF WOMEN. 113 

ovaritis. Metritis may supervene upon delivery, and ihe inflam- 
mation extend through the generative intestine 

Traumatic ovaritis. . , 

to the ovary, in some such manner as inflam- 
mation of the duodenum may indirectly extend to the liver. 

It is possible that, by reason of being compressed against the 
bony pelvis, the ovaries are sometimes injured during labor, but, 
as the gravid uterus occupies the superior strait, this result could 
happen only in exceptional cases. In the puerperal state, the 
absorption of post-organic matters from the cavity of the womb 
sometimes gives origin to a painful and dangerous form of this 
disease. Pus and other deleterious products may be conveyed 
by the oviduct from this cavity direct to the ovary, or lodged in 
the peritoneum, and thus serve to light up the inflammatory 
process. 

In rare cases, the rheumatic diathesis acts as a predisponent of 
ovaritis. This is an inveterate form of the complaint. In an 
example of the kind that I now have under treatment, the patient 
has, for six years, suffered almost martyrdom from rheumatism. 
For six months past she has had amenorrhoea, with prolapse of the 
left ovary, and ovaritis. A peculiarity worth mentioning is 
that an elder sister of hers died of rheumatism with menstrual 
suppression that had persisted for more than a twelvemonth. 

The "hysteric constitution," as it is styled by Robertson, is a 
marked predisponent of ovaritis. The class of patients most lia- 
ble to this inflammation are recognized as the nervous, irritable, 
and hysterical, those whose temperaments are mercurial and 
volatile. 

Symptoms. — In acute, post-partum ovaritis, the constitutional 
symptoms are marked and decided. As in inflammation of the 
serous tissues generally, the attack commences 
with a chill, followed by fever, acceleration of 
the pulse, and local pain. This pain is sometimes described as 
sharp and intense ; again it is forcing, throbbing, or dull, sicken- 
ing and paroxysmal. It may be seated in the upper and posterior 
portion of the vagina, in one or both of the iliac fossa3, the groins, 
the lumbar region, the sacrum, the hips, or in the thighs, and occa- 
sionally reaches to the end of the toes. Sometimes, in lieu of a 
positive pain, there is a disagreeable feeling of weight and smart- 
ing in the region of the ovary, and patients not ^infrequently com- 



114 LECTURES, CLERICAL AND DIDACTIC, 

plain of a burning sensation in the same locality. On applying 
the hand to the hypogastric region, you may discover that there is 
really an increase of heat in the part affected. 

When decidedly paroxysmal, the sufferings may either remit or 

intermit. The iliac and hypogastric regions become exceedingly 

sensitive to the touch, so that pressure, palpa- 

Exercise — position. . _ . . , 1 „,.. 

tion and percussion are insupportable. Ihe 
least motion, more especially the attempt to sit upright in bed, 
increases the suffering, and syncope may result. In milder cases, 
riding and walking have a similar effect. One of my patients 
complains most of riding in a railway car. The thigh that cor- 
responds with the affected side is sometimes flexed, cannot be 
extended without causing much suffering, and on this account is 
rendered almost useless. She cannot sit, or stand erect, without 
extreme pain. When in the horizontal position, she prefers to 
keep the thigh flexed on the abdomen, and the leg on the thigh, 
in order to procure ease by relaxing the intra-pelvic and abdomi- 
nal muscles, and thus relieving pressure upon the tender and 
inflamed ovary. 

If the lesion involves any considerable portion of peritoneum, 

you may expect general abdominal tenderness, with tympanites, 

and other symptoms of true peritoneal inflam- 

Peritoneal ovaritis. . ..,,., 

mation. In post-partum ovaritis, whether it be 
a sequel to labor at full term or to abortion, the disease has its- 
origin in this membrane (which is reflected over the ovary), 
whence it spreads rapidly. 

In consequence of its increased weight, produced by a species 
of strangulation and inflammation, the ovary is liable to a hernia 
or descent, posteriorly into the recto-vaginal space or cul-de-sac, 
laterally along the sides of the vagina, anteriorly between the 
uterus and the bladder, and even occasionally into the labia 
majora. In rare cases, this hernia of the ovary is congenital. 

The following interesting case of this kind is cited by Billard, 
(Traite des Maladies des Enfants nouveau-nes. Paris, 1833, p. 
474). 

" Josephine Romer, seventeen days old, was brought to the 
Infirmary, September 12th. She was strong, and seemed pos- 
sessed of a good constitution ; the abdomen was somewhat tense ; 
and at the left inguinal region there was a round tumor of the 



ON THE DISEASES OF WOMEN. . 115 

size of a filbert, somewhat hard to the feel, which could not be 
returned to the abdomen, neither reduced in size by pressure, nor 
was its volume increased by the crying of the child. Its direction 
was obliquely towards the labium of the corresponding side, which 
it did not quite reach. On considering the location of the tumor, 
and although the sex of the child forbade the supposition, one 
could hardly resist the conviction that it was a congenital ingui- 
nal hernia. Our judgment was accordingly suspended until, at the 
end of twenty-six days, the death of the child from pneumonia 
allowed us, by dissection, to ascertain the nature of the tumor. 

* * * * The hernial tumor was formed by the left ovary, 
that had descended through the inguinal canal and ring, which 
were much larger than one usually finds them in girls. The 
uterus, drawn by the round ligament, and by the ovary that formed 
the hernia, had left its natural position, and was inclined to the 
left side of the bladder. The left kidney, instead of being on a 
level with the other, was drawn downward by an enveloping cel- 
lular tissue, and also by a fold of peritoneum, intimately con- 
nected with the orifice of the sac ; the renal artery and vein had 
also yielded to this traction, and both were elongated and nar- 
rowed ; and finally, the ovary and the fimbriated extremity of the 
Fallopian tube, somewhat reddened and swollen, were lodged at 
the base of the sac formed by the prolongation of peritoneum, 
with which cavity it communicated. There were no adhesions 
between the intestinal convolutions and the surrounding parts, 
and the opposite ovary was in its usual situation. 

" A careful examination of the round ligament on the side where 
the hernia was, satisfied me that it was much shorter than that of 
the opposite side, and that, in place of losing itself in loose fila- 
ments, it terminated in the labium by an aponeurotic expansion ; 
from which it would seem that the ligament, shorter, and more 
firmly fixed to the labium, had, in the first place, caused the 
uterine displacement, and subsequently drawn the ovary through 
the inguinal ring. It followed, from this abnormal adhesion, that 
all the movable, connected and contiguous parts on the left side of 
the abdomen were drawn to the side of the hernia, for they were 
not separated from each other, nor did they follow the abdomen 
in the intra-uterine development and enlargement of the foetus." 

The benign tumor formed by the displacement in ovaritis, 



116 LECTURES, CLINICAL AND DIDACTIC, 

may vary in size from that of a large almond, to that of a hen's 
egg, or even larger. It is more swollen and sensitive at each men- 
strual period. This drawing, on the blackboard, will give you a 
pretty correct idea of the posterior and more frequent dislocation 
of the ovary, which you will remark has dropped into the recto- 
vaginal pouch, so that it is situated between the anterior wall of 
the rectum and the posterior wall of the vagina. 

The swollen ovary feels like an enlarged gland, is convex, and 
sometimes throbs and pulsates beneath the finger. The anal and 
vesical symptoms correspond with the variety and extent of the 
ovarian displacement. As a rule, the lower the organ, the greater 
the suffering. The tumor may press upon the broad ligaments 
and cause uterine deviations, or upon the veins and nerves within 
the pelvis, and occasion great suffering, paralysis, and, according 
to Cams, convulsions of the inferior extremities. 

But since, as Becquerel insists, these symptoms are common to 
inflammation of all the organs contained within the lower pelvis, 
how are we to decide, in a given case, if they depend upon ova- 
rian inflammation and consequent displacement ? In the more 
acute attacks of ovaritis, and particularly in lean persons, it is 
sometimes possible to detect the tumefied organ by examination 
through the abdominal parietes. In this case the swelling is cir- 
cumscribed and extremely painful to the touch. This is the most 
severe, or peritoneal form of the disease, which Scanzoni teaches 
" is the only form accessible to palpation." 

In diagnosticating the sub-acute and chronic varieties, it is nec- 
essary to resort to the " touch." Upon making an examination 
per vaginam, we find the "tender spot" com- 

The vaginal u touch." , A - 

plained of to correspond with the position of 
the prolapsed ovary. We may discover the tumor at the right or 
left sacro-iliac symphysis, or in one of the sacro-sciatic notches. 
If the displacement is a lateral one, we may confirm our suspicions 
by an examination of the corresponding groin, or iliac region, 
through the abdominal walls with one hand, while with the other 
we explore the vagina. 

It frequently happens that the patient winces or complains when 
... the finger touches the uterine os or cervix — a 

Characteristic pains. , 

circumstance that, unless one is very careful, 
may mislead in the diagnosis. Pressing the vaginal portion of the 



OX THE DISEASES OF WOMEN. 11 T 

cervix, backwards and laterally, occasions acute pain in the af- 
fected ovary. She declares that " she cannot bear to be touched 
just there," and may proceed to tell you that the same suffering is 
sometimes caused by contact of the male organ with that spot 
during coitus. One of my patients made a similar complaint in 
consequence of having touched the posterior vaginal wall at its 
superior portion, with the pipe of her syringe, which she had been 
told must be introduced high up into the vagina. 

The displaced and inflamed ovary is most easily felt upon exam- 
ination by the vagina when that canal is short, and the uterus and 
its appendages are not far removed from the 

The rectal " touch." i t» i 

vulva. But when the vagina is long, and the 
womb high up in the excavation, it is necessary also to 
resort to the expedient of exploration by the rectum. Plac- 
ing the patient in the obstetric position, with the thighs well 
flexed, the finger introduced into the rectum may be made to 
reach further, and acquaint us more fully with the degree of ova- 
rian swelling and displacement, than any other means at com- 
mand. This end is facilitated by the thinness and elasticity of 
the coats of the rectum, and the possibility of exploring the pos- 
terior surface of the womb, and even of the ovaries, in their nor- 
mal state. And this mode of examination may be rendered still 
more valuable in certain cases, by the employment of the free 
hand in abdominal manipulation — it being sometimes possible 
thus to press the tumor upon both its anterior and posterior sur- 
faces at the same moment. 

In the worst examples of prolapse of the ovary into the recto- 
vaginal space, the same end is gained by a resort to what has been 

styled the " double touch" of Recamier, which 

The " double touch." . , . -. . /» 

consists m the introduction of the index 
finger into the rectum, and of the thumb of the same hand into 
the vagina. By forcing the perineum upward, this expedient 
permits us to compress the morbid growth between the thumb 
and finger. The character of the resulting pain, and the shape, 
position and mobility of the tumor, are believed to be pathogno- 
monic of the disease in question. 

One of the most painful and persistent symptoms consequent 
upon a posterior prolapse of the inflamed ovary is an intolerable 



118 LECTURES, CLINICAL AND DIDACTIC, 

sense of strangulation and obstruction of the bowel, following 
the effort at stool. Rigby compares the charac- 

Feeling of strangulation. _ . „ , . /« . ,-, , 

ter and quality ot this suffering to that proper 
to orchitis, which, as you know, is almost insupportable. It is 
undoubtedly due to the pressure of faecal matter, and to the peri- 
staltic movements of the rectum upon the dislocated, swollen and 
excessively tender ovary. It may continue for hours after defe- 
cation has been accomplished. The symptoms induced thereby 
are sometimes mistaken for those of retroversion of the womb, and 
of stricture of the rectum. Constipation is an almost necessary 
consequence ; and it is possible, as has been claimed, that, in some 
cases, it ma}' even tend to produce the displacement of the ovary. 
The whole alimentary system is liable to be deranged. The 
tongue becomes coated, the patient complains of thirst, anorexia, 
and, in rare cases, of obstinate heartburn, and even vomiting, as 
in the early months of pregnancy. The febrile sj'mptoms corre- 
spond with the suddenness and severity of the attack. 

The vesical symptoms are sometimes so pronounced as to lead 
to suspicion of idiopathic disease of the bladder, and possibly of 

the kidneys also. When there is strangury, 

Ves 1C al symptoms. . J . ■ 1 

dysuria, heat and pressure m the bladder, and 
these symptoms are greatly aggravated, or recur, only at the men- 
strual period, they signify that a sub-acute inflammation of one or 
both ovaries may be the cause of the suffering. You are not to 
conclude that they are necessarily the result of anteversion of the 
uterus, which affection, I repeat, exists more frequently in im- 
agination than in fact. 

The menstrual irregularities incident to ovaritis will not fail to 
attract your attention. The physiological theory that menstrua- 
tion consists essentially in the ripening and discharge of the unfe- 
cundated egg, or the " parturition of the ovum," as Tyler Smith 
most appropriately terms it, is now the generally received explana- 
tion of this process. 

The ovary is par excellence the organ of menstruation ; the ma- 
turation and extrusion of the ovum, the first direct step in the 
process. This little organ, at once the most diminutive and im- 
portant of all the pelvic viscera, is a species of alarm clock, that 
introduces the element of time into the generative system, and 
presides over this function with respect to its occurrence and 



ON THE DISEASES OF WOMEN. 119 

xegularity. Its organic symptoms are wonderful, and almost 
unlimited in their range and significance. Physicians are accus- 
tomed to speak of the " uterus and its appendages ;" a more cor- 
rect phraseology would be, " the ovaries and their appendages." 

Retention of the menses is one of the most common and serious 
symptoms of sub-acute and chronic ovaritis. Young women are 

especially liable to that form of amenorrhcea, 
demTo^varkis 5 . ^ 61 " 5 ind ~ described by the older writers as emansio men- 

sium, a condition in which the menstrual flow 
has never been established. When a simple suppression of this 
discharge — suppressio mensium — occurs during the course of 
other diseases ; as, for example, in phthisis pulmonalis, and the 
protracted fevers, or from incidental causes, it may signify that one 
•or both ovaries are inflamed. The cause has operated indirectly. 
The lesion is secondary or symptomatic. The effect is noile the 
less palpable, and equally prejudicial to a complete recovery. 

It is impossible to treat properly such cases of menstrual irregu- 
larity without a knowledge of their special pathology. Some 
slight obstruction prevents the escape of the menses from the 
uterine cavity or the vagina. The new and abnormal pulse is 
reflected upon the ovary. Inflammation is the result, and the 
regularity and completeness of the function is disturbed for 
months, and possibly for years. Not to speak of the harmful con- 
sequences supposed to result from the non-elimination of certain 
matters contained in the menstrual blood, the suspicious charac- 
ter of the vicarious hemorrhages ' sometimes induced, or the lia- 
bility in many cases to the development of pectoral disorder from 
this cause, there is no question but that, in the great majority of 
instances, amenorrhcea is intimately connected with, and depend- 
ent upon, ovaritis. 

The varieties of dysmenorrhea known as spasmodic, mechani- 
cal, and obstructive, implicate the ovaries in a similar manner, 

and are, therefore, to be regarded as incident 
^ Dysmenorrhea and ova- to? an( j not d e p en dent upon, the disease under 

consideration. The ovarian form of dysmenor- 
rhea is always accompanied by ovaritis. The physiological injec- 
tion of the organ, so necessary to its functional activity, becomes 
excessive and exaggerated. The first stage of the inflammatory 
process is present, and the congested viscus is tender and painful. 



120 LECTURES, CLINICAL AND DIDACTIC, 

All the suffering, which is paroxysmal, tormenting, and neuralgic 
in character, may be referred to the ovary. The lower part of the 
abdomen becomes extremely sensitive, and the patient undergoes 
a monthly martyrdom, accompanied by a distressing headache,, 
neuralgia, and hysterical symptoms of every shade and variety. 

In my lecture on menorrhagia, you will recollect that I called 
your attention to the clinical fact that the most inveterate ex- 
amples of that affection had their origin in sub- 

Menorrhagia and ovaritis. 1 .. . ™ . n 

acute and chronic ovaritis, lo members 01 our 
school of medical faith, this fact is especially significant. The 
recognized superiority of our remedies for the arrest of profuse 
flooding can only be explained by their power to regulate, harmo- 
nize and restore the delicate vascular sympathies that exist be- 
tween the ovaries and the uterine mucous membrane. In illus- 
tratiorr, I will read you the notes of a case upon which my advice 
was desired by Dr. B., a member of the class from Wisconsin. 

Case. — Mrs. , aged 18, married one year, came under my 

professional charge about three years ago. She is troubled with 
menorrhagia. The attacks have recurred at intervals for a period 
of two years, for the relief of which she has taken domestic and 
allopathic medicines in large quantities. She was formerly strong 
and robust, but, on taking a sudden cold during the catamenial 
period, the menses were suppressed for nearly a year immediately 
preceding her last illness. The attacks of flowing last for a 
period of one or two weeks, and weaken her so much that she can 
scarcely raise her hand. The interval varies from three to four 
weeks, but is sometimes extended to eight or ten weeks. The flow 
is always long-continued, and profuse in amount. She had lost 
all reckoning as to the time for the recurrence of the regular flow. 

The discharge is sometimes dark and clotted, but more frequently 
of a thin, fluid character. Sometimes — and especially when the 
clots are passed — it is attended by much suffering, but, except- 
ing in the region of the ovaries, there is in general no pain. Both 
ovaries are tender and exceedingly painful, but only during the 
flow. 

She had been taking internally, and also by injections into the 
womb, most of the astringents laid down in the Materia Medica. 
In three months, by the use of pulsatilla, sulphur, nux vomica 
and sabina, giving the first two night and morning for a fortnight, 
and the last two for a like interval, and then repeating, I suc- 
ceeded in establishing the regular ^periods.*' Menstruation 
would then seem to be natural, the proper flow to continue for 
three or four days, after which, instead of decreasing, it would 



ON THE DISEASES OF WOMEN. 121 

increase, and consist of clots with arterial blood. The discharge 
would then continue for ten days or a fortnight, despite my best 
efforts to suppress it. For a time, drop doses of hamamelis 
seemed to check it, but after a little it lost its effect. 

This patient has never had any children, or, to her own knowl- 
edge, ever been pregnant. At times she has leucorrhcea, which is 
readily relieved by appropriate remedies. When I first saw her, 
the appetite was morbid, and she had lived upon rich and highly- 
seasoned food. She craved pickles especially. 

In this case, the nature of the exciting cause, the amenorrhoea, 
and the ovarian tenderness, assure us that the haemorrhage could 
not have been due either to prolapsus uteri, hydatids, or a cancer- 
ous affection of the womb. The doctor's success in establishing a 
periodical return of the menstrual flow is confirmatory of the view 
that its essential pathology was to be sought for in the ovaries. 
The throwing of astringent injections into the uterine cavity, by 
his predecessor, was a species of malpraxis which, besides being 
a positive injury, demonstrated the ignorance of the practitioner. 

Gonorrhceal ovaritis is, I am persuaded, more frequent than is 
generally supposed. According to M. de Meric ("London Lan- 
cet" for September, 1862), it is most liable to 

Gonorrhceal ovaritis. . 

occur during the acute stage of gonorrhoea m 
the female. In this it differs from the onset of orchitis in the male, 
which occurs towards the decline of the gonorrhceal discharge. 
This rule has many exceptions. The same author states that such 
an effusion and induration as takes place in the epididymis, when 
the testicle is inflamed, does not occur in the ovary in consequence 
of gonorrhceal ovaritis. Nevertheless, the character of the suffer- 
ing induced is very similar. However much the patient may com- 
plain of the vaginitis and urethral symptoms in case of gonorrhoea, 
the acuteness and severity of the pain in one or both ovaries, 
when they are the seat of this specific inflammation, is still more 
marked and decided. It closely resembles that of orchitis. 

As a concomitant of gonorrhoea in the female, ovaritis may 
undoubtedly result, as Dr. Tilt suggests, from " the immediate 
application to the ovaries of the blenorrhagic pus which has been 
conveyed by the same capillary attraction by which the seminal 
fluid is conducted ; " from extension of the disease from the 
vagina ; or possibly from inoculation of the whole glandular sys- 
tem, including the ovaries themselves, with the specific poison. 



122 LECTURES, CLINICAL AND DIDACTIC, 

The excessive tenderness of the vagina in cases of this kind, inter- 
poses a barrier to the employment of the "touch" in making a 
careful diagnosis, and hence this affection has been overlooked by 
a majority of writers and practitioners. I can not give you a 
better idea of this form of the disease than by quoting a case from 
M. de Meric's excellent paper. 

" On October 27, 1858, 1 was asked to see the wife of a wealthy 
tradesman in one of the metropolitan suburbs. She was said to 
be very ill, and I found her in bed. The patient was then about 
thirty-two years of age. She stated that, for three weeks at 
least, she had noticed an abundant discharge, which had consid- 
erably stained her linen with large yellow spots. The discharge 
had of late increased, and she had been obliged, on the day of my 
visit, to take to her bed, owing to a severe pain in the left iliac 
region. There had been a certain amount of uneasiness in mic- 
turition, but that had passed off. The last menstruation had 
occurred about three weeks before. 

" On examination, I found the patient suffering from feverish- 
ness ; the linen shown to me was marked with large yellowish 
spots, and pain on pressure over the left ovary was very acute. 
The diagnosis of a case of this nature was seemingly easy enough. 
I suspected sub-acute metritis, the inflammation having suddenly 
extended along the Fallopian tube, and reached the ovary. This 
latter circumstance was explained by an imprudent exposure to 
cold, viz., driving home from the theatre in an open carriage. The 
pain was so acute that I did not propose a vaginal examination, 
but at once ordered fomentations to the left iliac region, a gentle 
purgative, an antimonial mixture, low diet, and rest. 

" It should be noticed that the lady was suckling a child about 
seven months old. 

" On leaving the house, the husband accompanied me, and 
inquired about the state of his wife, hoping it was nothing seri- 
ous. As he had been under my care, some years before, for gonor- 
rhoea, I thought it my duty to ask him whether anything of the 
kind had happened again ; and I learned that he had been suffer- 
ing from a slight discharge, which was going off. 

" The case now took a different aspect; and, after weighing all 
the circumstances, I came to the conclusion that my patient had 
been infected, and was laboring under gonorrhoea, the inflam- 



ON THE DISEASES OF WOMEN. 123 

mation having traveled to the ovary by way of the uterine 
cavity. 

" On the 29th, two days after my first visit, I saw the lady 
again, and found the discharge had diminished ; the pain over the 
left ovary was still severe, though the pulse had somewhat come 
down. I proposed leeches, but so much repugnance was expressed 
that I advised counter irritation by mustard poultices, and the use 
of the same lowering means. The case progressed very favora- 
bly ; a few astringent injections were made as soon as the acute 
inflammation had gone by ; and in about three weeks the patient 
had so far recovered as to resume her household duties. I did not 
think it necessary to advise the weaning of the child. The father 
also regained his health in a short time." 

Some most painful attacks of gonorrheal ovaritis arise from the 
use of strong astringent injections designed to stop the vaginal 
flow. I have recently treated a case of this kind, in which the 
husband ventured to prescribe the same injection for his wife that 
had been ordered for himself by a quack doctor. After a few 
hours she did penance for his infidelity and presumption, in a most 
severe attack of inflammation seated in both ovaries. Women 
sometimes resort to such harmful expedients at their own sugges- 
tion, and in a fit of desperation. I am greatly mistaken if in the 
future your professional experience does not prove that ovaritis 
is a frequent and most painful contingent of gonorrhoea in the 
female, Dr. Simpson and others to the contrary notwithstanding. 

At my next lecture I shall speak of the pathological anatomy, 
the differential diagnosis, prognosis, sequelae, and treatment, of 
ovaritis. 



124 LECTURES, CLERICAL AND DIDACTIC, 



LECTURE VII. 

ovaritis — (continued). 

Gentlemen : 

In my last lecture your attention was directed to the nature, 
causes and symptoms of ovaritis. As related to the history and 
treatment of this disease, other points remain to be noticed. And, 
first, of its 

Pathological Anatomy. — You will not be surprised to learn that, 
until quite recently, the physiological anatomy of the ovaries was 
so little understood that distinguished physicians have been known 
to mistake healthy for morbid appearances, in these organs, at post 
mortem. It is related of the eminent anatomist Yesalius, that he 
referred the origin of symptoms of uterine strangulation, amenor- 
rhcea, and chlorosis, to the presence of yellow spots, the modern 
corpora lutea, in the ovaries of four unmarried women, upon whose 
bodies he conducted an autopsy. 

The structural changes incident to ovaritis vary with the acute- 

ness of the attack, the brevity of its course, the seat of the lesion 

in one or another of the ovarian textures, its 

The lesions vary. . 

relation to the last menstrual period, to labor, 
whether premature or at full term, and to the grand climacteric. 
As with inflammation seated in other organs, so in ovaritis, the 
more rapid the course of the disease, and suddenly fatal the attack, 
the more marked are the evidences at post mortem of congestion, 
and its immediate consequences. 

The line of demarcation that separates the physiological changes 
proper to the maturation of the ovum and the dehiscence of the 
follicle at each menstrual period — id est, the escape of a small 
amount of blood into the cavity of the Graafian vesicle, the retrac- 
tion of its walls, the formation of a clot, the fading hue of the 
coagulum, and the final cicatrix — from the more marked encrorGfe- 
ment and effusion proper to acute attacks of ovaritis, is very inclis- 



ON THE DISEASES OF WOMEN. 



125 



tinct and illy denned. In this connection, the following differential 
diagnosis between healthy and morbid ovisacs, as detailed by Dr. 
Farr, and re- arranged by Dr. Clay, in his notes to 'Kiwisch,* is of 
practical interest : 



NATURAL FOLLICLE. 

I. Always near the surface when prepar- 
ing for dehiscence, and often projects 
considerably above the level of the 
ovary. 



2. Coats unequally thick ; thinnest at the 
most prominent part of the follicle. 

3. Considerable vascularity above the 
elevated part, plainly visible exter- 
nally. 

4. Walls of follicle at this stage, of a 
bright yellow color. 



The liquor folliculi is either clear and 
limpid, or intermixed with blood, or 
the center of the sac is filled with a 
coagulum, which is at first bright red, 
and afterwards becomes pale, and at 
length nearly white. The coagulum 
may adhere to the walls, and undergo 
fibrillation and subsequent conversion 
into a solid body, or into a dense white 
membrane ; or it may be rapidly 
absorbed. 



MORBID FOLLICLE. 

Often not peripheral, but more or less 
central in its position in the ovary. It 
may attain to the size of one-third or 
half of the ovary, without necessarily 
causing any distinct prominence above 
the surface, especially when occurring 
singly. 

Walls are equally thick, and exhibit at 
no part any evidence of attenuation or 
absorption. 

No preparation for rupture is indicated 
externally, by any peculiar arrangement 
of vessels, or by any marked increase of 
vascularity. 

The walls do not exhibit the remarka- 
able yellow color, or the cerebral fold- 
ings, characteristic of the advancing 
normal ovisac, the tissues being com- 
posed of the undeveloped Graafian 
follicle. 

Contents of the sac are neither the 
clear liquor folliculi, nor the bright 
clot, nor the developed fibrin, but gen- 
erally a collection of dark coffee-ground 
matter, resulting from the admixture 
of a quantity of decomposing blood 
corpuscles, and fragments of membrana 
granulosa, intermixed with a dirty fluid. 



Any considerable engorgement of the ovary with blood, occa- 
sions an increase in the size and weight of the organ. The tum- 
efaction is accompanied by softening of tissue, 
^ The discoloration and the increased vascularity, and a change of color to 
a rusty dark red or blue, or even a mahogany 
hue. In idiopathic cases, which are rarely the subject of post 
mortem examination, an apoplectic effusion of blood into the fol- 
licles, and the subsequent formation of a coagulum therein, some- 
times results. As in cerebral apoplexy, the size, complexion, and 
character of this coagulum varies in different cases and in differ- 
ent stages of the disease. The masses are irregular or rounded, 



* Kiwisch on the Diseases of the Ovaries, by Clay, London, 1S60, p. 63. 



126 LECTURES, CLINICAL AND DIDACTIC, 

and sometimes as large as a cherry. The softer the clot, and the 
lighter its color, the more chronic or protracted has been the 
inflammatory process. Recent effusions may supervene upon 
those of earlier date, in which case different follicles will be occu- 
pied with coagula of varying hues and consistency. Sometimes 
the wall of the follicle is hypertrophied, and rendered more firm 
than natural. In rare cases it is friable, and this species of hae- 
matic cyst may be ruptured, and its contents extravasated within 
the stroma, and the enveloping membrane (tunica albuginea) of 
the ovary, or into the peritoneal sac. Scanzoni details the case of 
" a young girl of eighteen years, who died suddenly during men- 
struation, with all the signs of an internal haemorrhage. The 
autopsy demonstrated in the right ovary, which was slightly 
amplified, a pocket of the size of a pullet's egg 

Haemorrhage into the ovary. „,, -, . , , . , . ' 

rilled with coagulated blood, in the posterior 
wall of which was found an opening of nearly nine-tenths of an 
inch long, through which nearly seven pounds of blood had pene- 
trated into the abdominal cavity." In septic states of the blood, 
as in the ovaritis of lying-in women, caused by the absorption of 
post-organic matters from the cavity of the uterus, the ovary may 
be engorged with effused blood from passive haemorrhage. These, 
and similar disclosures by the knife of the anatomist, have some- 
times caused the ovarian lesion to be entirely overlooked, and an 
off-hand, uninstructive diagnosis of pelvic hematocele to be made 
by the physician. 

Any of the various "terminations " of inflammation may some- 
times be recognized in the ovary. A very considerable effusion of 
serum into the peritoneal investment of the 

Dropsy as a sequel. x , . . 

organ, or the collection of the same fluid m the 
distended vesicles, discloses a dropsical condition that may have 
escaped notice during the life of the patient. In the former case 
the tumor is unilocular, in the latter multilocular. It is more than 
probable that, as in pleurisy and pericarditis, this serum is at first 
exuded as a critical means of relief to the inflamed structure, and 
that subsequently the absorbents are not capable of removing it. 
When resolution has taken place, the structure of the ovary is 
changed. The retracted cicatrices make it more solid in consis- 
tence, with an irregular, bosselated surface. The glandular 
structure disappears, and may be substituted by various forms of 



ON THE DISEASES OF WOMEN. 127 

heteroplastic growth ; as, for example, the cartilaginous, calcare- 
ous, cancerous, and possibly the tuberculous. Nearness to the 
grand climacteric increases the liability to atrophy of the whole 
organ. 

Puerperal ovaritis, whether peritoneal, parenchymatous, or fol- 
licular, and whether it occurs as a contingent of labor at full 
term, or in abortus, is most liable to terminate 

Liability to suppuration. . . 

in suppuration. Abscesses ot the ovaries are 
by no means uncommon. Their history is of the greatest clinical 
interest and importance. After death from puerperal fever, the 
puriform exudation may sometimes be found deposited in the folli- 
cle, which is thus enlarged to the size, perhaps, of a hazel nut. 
A description of these abscesses is thus given by Kiwisch (op. 
eit. p. 90) : 

" Follicular abscesses, after a long continuance, may attain a 
very considerable size ; indeed, according to our own observations, 
they have contained about sixteen pounds of pure pus. The cyst 
wall may resist perforation for some time, and, in isolated cases, 
for a long period of years. The parenchymatous abscesses are 
generally not so large, though we have seen them reach the size 
of a child's head ; and we have also to observe that they com- 
monly increase much quicker than those previously mentioned. 
These abscesses often proceed from several small foci, which coal- 
esce in the course of time, and the greater part of the stroma of 
the ovary is destroyed, or a sinuous cavity is inclosed in its rudi- 
ments. After a protracted duration of the disease, these collec- 
tions of pus are surrounded by a membrane ; but it is difficult to 
separate from adherent parts, and it cannot be anatomically 
demonstrated to any extent. The disposition to perforation is 
a characteristic feature of these abscesses ; in the acute form of 
the disease, it may take place in the course of a few days or weeks. 
The cystless abscesses in the neighborhood of the ovaries, are 
also disposed to perforation. Consecutive collections of pus, in 
previously degenerated follicles, seldom burst, with the exception 
of those cases in which the contents have an ichorous property." 
The pus contained in the ovarian abscess, in most cases, is laud- 
able ; but, occasionally, ichorous and corrosive. 

Character of the pus. .. #» . " i i ,' C 

The danger or rupture and extravasation ot 
the contents of these abscesses, is proportionate to the bad 



128 LECTURES, CLINICAL AND DIDACTIC, 

quality of this purulent matter, complicated perforations being 
more frequent where the pus is of an ichorous and disorganizing 
character. 

The abscess may discharge its contents directly into the abdo- 
men, with fatal consequences. A case of this kind is cited by Dr. 
Seymour, from Guy's Hospital Reports.* 

" The patient was a young woman, of the lowest and most un- 
fortunate class of females. She was greatly emaciated, had a 
very quick and feeble pulse, a shining red tongue, and constant 
watchfulness. She suffered from constant and irrepressible diar- 
rhoea, and for many successive days vomited both food and medi- 
cine ; the catamenia were absent. * * * * After having 
been in the hospital about two months, she suddenly complained 
of the most acute pain over the abdomen, and, in a few hours, 
expired. 

" On opening the abdomen, death appeared to have been pro- 
duced by the effusion of a large quantity of pus into the peritoneal 
cavity, which escaped from an abscess in the right ovarium, which 
abscess appeared to arise from suppuration in the substance of the 
viscus, similar in every respect to phlegmonous abscess in any part 
of the body, and not connected with any cyst, or change, or addi- 
tion of structure, the product of morbid growth." 

Collections of benign pus in the ovaries may find an outlet 
through the bowels, the bladder, the uterus, the vagina, or the 
abdominal parietes. They seldom perforate the 
Extemporized outlets for sma ll intestine, but more frequently communi- 
cate with the rectum, on the left side, and the 
colon on the right. Serious consequences, from the escape of the 
purulent collection, are prevented, by the formation of adhesions 
between the neighboring structures. Many obscure cases of renal, 
uterine, and rectal disease originate and culminate in this effort of 
nature to extemporize an outlet for the contents of an ovarian 
abscess. Fistulous abscesses of this sort are sometimes salutary, 
and again intractable, chronic, and necessarily fatal. In rare 
cases they may discharge, repeatedly, through the unnatural out- 
let. It should not be forgotten that, although it may take place 
in the unimpregnated female, ovarian suppuration occurs most 
frequently, in consequence of post-partum injury or inflammation. 

* Seymour on Diseases of the Ovaria ; p. 38. 



ON THE DISEASES OF WOMEN. 129 

The quantity of pus contained in the ovarian abscess may vary 
greatly. In most cases it is not very large. Examples are, how- 
ever, recorded, in which an incredible amount 
pufformeT quantity of nas been observed. Dr. Taylor, of Philadel- 
phia, reports a case of chronic ovaritis affecting 
the right ovary, in which the sac weighed seventeen pounds, and 
yielded sixteen quarts of pus. It sometimes happens that the 
purulent matter, with which the stroma of the ovary and the 
tissues of adjacent organs are infiltrated, is itself decomposed. 
In this case the evidences of fatal peritonitis are superadded to 
lesions already noted. Kiwisch says (op. cit. p. 92) : 

" The more acute the progress of an ovarian abscess, the 
slighter is the thickening of its walls, and the more benign its 
pus ; but much more frequently it happens that, after its contents 
have been evacuated externally, complete contraction and 
obliteration of the pus cavity takes place. This is observed 
particularly after parenchymatous inflammations, and the intra- 
peritoneal suppurations surrounding the ovaries. Those absces- 
ses, however, whose walls are highly organized, which are not 
excavated for months or years, particularly when the point of 
rupture has no favorable direction, generally cause exhaustion, 
in consequence of the frequent renewal of the decomposing pus, 
or become fatal by the supervention of pyaemia. " 

The post mortem disclosures in ovaritis, chiefly affecting the 
peritoneal investment of the ovary, are of the kind proper to 
serous tissues generally. Sometimes the most extensive adhesions 
are formed. " Thus the ovary may become agglutinated to the 
broad ligaments, to the pelvic parietes, the uterus, the bladder, or 
the rectum and the sigmoid flexure, to the caecum, the vermiform 
process, and the small intestine ; and it is generally attached to 
several of those viscera at the same time." The fibrous bands 
that connect these various organs and surfaces, belong to the 
variety of pseudo-membrane, classed by Laboulbe'ne as ''perman- 
ent," which are themselves subject to diseased conditions. In 
some cases a considerable increase in the size and weight of the 
ovary may be due to an excessive development of the fibrinous 
exudation. 

The various lesions we have detailed are seldom found uncom- 
plicated with those of inflammation of adjacent organs and 
9 



130 LECTURES, CLINICAL AND DIDACTIC, 

structures. This is especially true of puerperal ovaritis, which,, 
as we have said, is apt to run its course with metritis, endo- 
metritis, or peritonitis. 

Beraud, Trousseau and others, treat of a form of ovaritis which 
is contingent upon variola, (l'ovarite vario- 
leuse). It may attack either the parenchy- 
matous structure or the peritoneal envelop of these organs. 

Diagnosis — The diagnosis of ovarian affections is, sometimes, 

very difficult. This is especially true of the sub-acute and 

chronic varieties, unconnected with the puer- 

Characteristic symptoms. 

peral state. When the patient is extremely 
sensitive, and especially where it becomes necessary to explore 
the rectum, we may resort to the employment of anaesthetics with 
advantage. I have already given you a full description of the 
symptoms of ovaritis. The character of the suffering, its periodi- 
cal aggravation with each return of the catamenia, the menstrual 
derangements incident thereto, the symptoms of strangulation 
and inflammation from a hernial descent, or other displacement 
of the floating organ, the circumscribed swelling, the constitu- 
tional effects, and the sequelae, are sufficient to enable you to 
distinguish this from other diseases of the female generative 

svstem. In making out the differential dia^no- 
sio^ prindple ° f U exclu " s ^ s °f ovaritis, in its various forms, it is well to 

proceed upon the clinical principle of exclusion. 
Having examined if there be any disease of either of the neigh- 
boring organs, and not finding it present in a given case, we are 
confirmed in our diagnosis that the affection is ovarian. As 
explained in my last lecture, the " touch" is an invaluable aid in 
all doubtful cases. 

Prognosis. — In the milder forms of ovaritis uncomplicated with 
organic disease of other portions of the generative apparatus, the 
prognosis is favorable. Very considerable structural changes 
may be resolved away, and the general health and vigor rein- 
stated. The most obstinate examples of this disease are com- 
plicated with menstrual disorders, more particularly with menor- 
rhagia. In the gonorrhoeal type, when it does not result in 
suppuration, the symptoms are likely to become intractable and 
obscure, although most cases recover sooner or later. When 
there is ulceration of the womb, and the patient has been under 



ON THE DISEASES OP WOMEN. 131 

treatment therefor, especially if the os and cervix have been 
frequently and severely cauterized, the prognosis should be 
guarded. 

When acute ovaritis supervenes upon abortion, the danger is in 
ratio with the advanced state of pregnancy at which the miscar- 
riage has taken place. The more advanced the 
af^rabo a mo e n fromovariti5 P er i°d °f gestation, the greater the danger. 
Much depends also upon the cause or causes 
that have produced the abortion. As the normal stimulus for 
uterine muscular contraction is derived from the ovaries, so it is 
reasonable to suppose that any agency that produces a like result, 
whether medicinal or mechanical, vital or villainous, must oper- 
ate through the same medium, and thus implicate these organs 
more or less seriously. The prognosis will vary accordingly. 

As a contingent of child-bed, the danger varies with the history 
of the previous labor, the patient's vigor of constitution, the cir- 
cumstances by which she is surrounded, the 
_ As a contingent of lying- care s h e receives, and the epidemic prevalence of 
puerperal peritonitis. The occurrence of rigors 
that alternate with fever of an irregular type, local ovarian pain 
and anguish, a frequent pulse, colliquative sweats or diarrhoea, 
suppression of the milk or lochia, with tympanites, dyspnoea, 
great prostration, and copious deposits in the urine, are untoward 
symptoms. Rupture of the haematic cysts, and of the ovarian 
abscesses, and the extravasation of their contents, may prove sud- 
denly fatal. Under these circumstances, the patient sometimes 
dies as abruptly and unexpectedly as if from perforation of the 
intestine in typhoid fever, or from the bursting of an aneurismal sac. 
Ovarian suppuration is not necessarily fatal. We should, how- 
ever, qualify our prognosis most carefully. Where the accumula- 
tion of pus takes place rapidly, especiahy dur- 

Danger from suppuration. . p 

ing lying-m, and symptoms ot adynamia, and 
decomposition of that fluid, are present, there is danger from 
purulent infection and infiltration. Other things equal, the more 
depraved the state of the blood, the greater the danger from 
ovarian abscess. If the formation of the "pus cavity" is slower, 
and its secretion more benign in character, and more especially if 
adhesive inflammation has served to protect the adjacent viscera 
from implication, and to afford a means of final discharge, the 



132 LECTURES, CLINICAL AND DIDACTIC, 

case may terminate favorably. Sometimes a period of months, or 
even years, is consumed in this critical process. If the case 
becomes thus chronic, there is danger from exhaustion, caused 
by the drainage of the patient's nervous energies and nutritive 
resources. This is especially true of scrofulous subjects, who 
present a cachectic appearance, and finally succumb to vital losses 
of this character. Becquerel* reports the case of a young woman 
of twenty-three years, in which death followed the discharge of 
an ovarian abscess into the rectum. Kiwisch says, (op. cit. p. 86) : 

" The course ot these pelvic tumors is various. In favorable 
cases, the tumor, and with it all uncomfortable symptoms, com- 
pletely disappears, after a duration of some weeks or months. We 
have observed tumors the size of an adult head, exceedingly hard, 
and apparently in direct contact with the external abdominal 
integument, terminate in that manner. In other cases, suppura- 
tion extends, and perforation takes place in various parts of the 
surrounding structures, finally terminating favorably. On the 
contrary, when the course is unfavorable, the continued or relaps- 
ing acute attacks, or the profuse suppuration, or the dissolution of 
these tumors, causes the exhaustion of the patient. A rare, fatal 
termination happened to us in one case, from strangulation of the 
adherent small intestine, two convolutions of which, strongly dis- 
tended by gas, burst spontaneously, during violent contraction." 

A spontaneous removal of ovarian tumors of various kinds, inci- 
dent to the inflammatory process, sometimes occurs. This may 
take place even when the tumors has become so 
tuSors! ution ° f ° varian lar » e as to be Pushed out of the lower pelvis, 
in order that it may have sufficient room for 
development, as happens with the uterus, or at about the fourth 
month. Dr. Meigsf relates several cases in illustration of this 
fact, from which we select the following : 

" May 23, 1852. I this day examined the hypogastric region of 
Miss M. This lady, who has a very great spinal curvature, was 
examined by me about nineteen or twenty months since. I then 
found a very solid, incompressible, and immovable tumor, large as 
a child's head at term, which occupied the hypogastric region, 
and which was not a womb. It appeared to come up out of the 

* Traite Clinique des Maladies de l'Uterus et de Ses Annexes, Paris, 1859. Tom. 
II ; p. 476. 

f Woman, her Diseases and Remedies. Phila., 1859 ; P- 357- 



ON THE DISEASES OF WOMEN. 138 

pelvis. I considered it to be an ovarian tumor — and, of course, 
my opinion was, that it was incurable, and must, in the course of 
time, destroy her life. To-day, no trace of it is discoverable — 
nor is there any reason to suppose it exists. I take comfort from 
this example — one of the most extraordinary I have met with - — 
for all future cases of a similar character. I am wholly at a loss 
to account for its disappearance, since I am sure it was not a 
Jiypertrophied womb that I detected nineteen months ago — and 
that it was not any glandular or hygromatous tumor. She is well 
in February, 1859." 

Apart from the danger from rupture and discharge of its con- 
tents into the abdominal cavity, from the pressure and weight of 
the tumor when very large, and the drain 
ch?rgi n fr ° m excessive dis " upon the patient's strength to nourish and 
sustain the mass, some allowance should be 
made for the liability to recurrent attacks of peritonitis, which 
always imperil the life of the patient. The same may be said of 
co-existing lesions of adjacent organs. 

Adhesions, resulting from the formation of adventitious mem- 
branes are not more dangerous than those which are incident to 
other serous tissues when inflamed — as, for 
rai C c°ha S n q e encesofstructu " exam ple, the tunica vaginalis testis, or the 
pleura. They may take place in consequence 
of a slight attack of ovaritis, usually styled " menstrual colic," in 
the newly-married female, or from metastasis of mumps to the 
ovaries, as happens to the testicle in the male subject, without an}' 
untoward results. This remark applies also to simple hypertro- 
phy, atrophy, and induration of the ovaries. 

Cancerous, calcareous, cartilaginous, and tuberculous degenera- 
tion of the ovary necessitates an unfavorable prognosis — unless, 
indeed, the surgical expedient of excision may promise somewhat 
of good. 

Sequelce. — Besides the lesions already spoken of as incident to 
ovaritis, there are others that should not be overlooked. 

These are chiefly related to the functions of menstruation and 

generation. Menstrual derangements are very liable to follow 

ovaritis, whether it involves the follicular or 

the peripheral structure of the ovary. Many 

examples of amenorrhcea, dysmenorrhea, and menorrhagia, are 



134 LECTURES, CLINICAL AND DIDACTIC, 

to be regarded as sequelae to attacks of ovaritis, the more evident 
symptoms of which may long since have passed away. The tex- 
tural changes detailed when treating of the pathological anatomy 
of this disease, are sufficient to explain the menstrual sequelae 
which are so often entailed upon the patient. It would not be 
reasonable to expect that the delicate process of evolution could 
proceed in an uninterrupted, physiological manner, after the 
Graafian vesicles had once been transformed into haematic, serous 
or purulent cysts, and their walls hypertrophied, ruptured, or cica- 
trized. If blood or pus have infiltrated the stroma, or pseudo- 
membranous adhesions attached the organ to neighboring viscera ; 
if the fimbriated extremity of the Fallopian tube is bound down 
to the ovary, and that portion of the generative intestine occluded, 
the menses will either be entirely suppressed, or their escape and 
discharge become painful, scanty, insufficient, irregular, or too 
frequent and profuse. 

Nor are the evil results of these ovarian lesions limited to the 
ovaries. The intimate sympathy existing between these organs 

and the uterine mucous membrane is certain to 
mu!?ous C mem^ tne l att er in whatever pathological 

process affects the former. With each return 
of the catamenial period — no matter whether all its phenomena 
are present or not — this mucous membrane becomes highly 
injected and very vascular. If the proper flow is established, at 
the proper time, and in proper quantit}-, this physiological afflux 
of blood is quietly remedied and removed, as in the case of other 
mucous membranes after their secretions have been poured out. 
On the contrary, if the natural stimulus, originating in the ovary, 
is withheld, or perverted in its action or qualities, uterine de- 
rangements are a necessary consequence. Hence the intractable 
nature of many examples of sub-acute and chronic metritis. 
Moreover, a long chapter of reflex disorders ma}^ be indirectly 
due to the same cause. 

I am inclined to the opinion that, as a sequel to ovarian inflam- 
mation, sterility is more frequently met with than is generally 
„ .,. „ supposed. The history of menstrual disorders 

Sterility from ovaritis. . ^ 

and irregularities, just alluded to, confirms this 
idea. Indeed, whatever imperils the integrity of the catamenial 
function may also implicate fecundity. When lesions of the ova- 



ON THE DISEASES OF WOMEN. 16b 

ries are sufficient to prevent the completion of the process of ovu- 
lation, they also prevent conception. If inflammation of both 
ovaries were as common as that of a single one, sterility would be 
as familiar a complaint as almost any other. As it is, while one 
of them escapes, other things equal, the power to procreate is 
continued, by a species of compensatory relation, as in the case of 
the male, when one of the testicles is diseased or has been re- 
moved. Induration of both ovaries, when it occurs in conse- 
quence of disease, is as inevitable a cause as atrophy from old 
age. The ovaries may be so displaced as to remove them from 
the reach and grasp of the fimbriae of the Fallopian tubes. In this 
case they would have no communication with the uterine cavity ; 
and if the ovum were furnished by the follicle, it could not be 
conveyed to the womb. Sometimes, as a result of ovarian disor- 
ganization, diseased and imperfect ova are formed and furnished 
by the female. These may be impregnated, but subsequently are 
imperfectly developed, and abortion is a natural and necessary 
consequence. Hyperplastic formations and adhesions about the 
ovary may interfere mechanically to prevent conception, in some 
such manner as an excessive deposit of fat in the omentum some- 
times prevents women, who are remarkable for their pinguidity, 
from having children. 

Sterility is not an uncommon sequel to gonorrhoeal ovaritis. A 
moment's reflection will convince jou. that this variety of the dis- 
ease under consideration is more likely to affect 
rhSa r i r ovar?tis from s ° nor " Dotn ovaries at the same time than any other, 
not even excepting the puerperal form. The 
lesion resulting therefrom may involve the most serious conse- 
quences to the generative function. Hence sterility not unfre- 
quently follows an attack of gonorrhoea ; and those who have had 
gonorrhoea repeatedly, are not apt to become pregnant. "Without 
•doubt, this result is sometimes chargeable to the blighting effects 
of the specific virus upon the ova, which it destroys in some such 
manner as it does the vivifying influence of the spermatozoa in 
the semen masculinum. But I apprehend that, in the majority of 
cases, actual lesions of the ovary are produced by the modified 
inflammatory process, which lesions are sufficient to account for 
the sterility that follows. 

Bernutz styles ovaritis "female orchitis." In the male sub- 



136 LECTURES, CLINICAL AND DIDACTIC, 

ject inflammation of the testicle, accompanying or following a 
severe attack of gonorrhoea, may, and I believe frequently does, 
prove itself a cause of sterility. The same remark applies to those 
women who, having suffered from this form of ovaritis, find them- 
selves barren in consequence. 

My professional experience confirms this view. Physicians are 
often consulted for the cure of sterility in the persons of women 
whose husbands have been wild and profligate in youth, and 
whose bad habits may have perpetuated themselves. Careful 
inquiry into the history of such a case, may disclose that the 
patient has had one or more attacks of gonorrhoeal ovaritis, from 
which, indeed, she may be suffering at the moment of consulta- 
tion. It is more than probable that such examples of ovaritis are- 
modified by the specific gonorrhoeal taint, however faint the im- 
pression and remote its cause. This clinical fact affords a plaus- 
ible explanation of the source of difficulties among the higher 
families and orders of society, on account of their lack of progeny,, 
with which history and human experience abound. 

Although it may doubtless be true that, in exceptional cases, 
nymphomania results from ovaritis, yet experience has demon- 
strated that the most common effect of the dis- 
Nymphomania from ease } s ^ diminish rather than increase the 

ovaritis. 

sexual feeling. Dr. Ash well * says : " In two 
instances, I am perfectly convinced that the result of the malady 
was entire aversion to intercourse, and it is now allowed that 
nymphomania more generally depends upon the external organs,, 
so far as physical causes are concerned." 

Treatment. — This is divided into general and local. Owing to 
the present imperfect state of the materia medica, the pathoge- 
netic indications for remedies in the treatment 

General treatment. _ . . . 

of ovaritis are neither very explicit nor very 
numerous. Its special therapeutics must, therefore, be founded 
upon our knowledge of its pathology, the proper use of such 
provings as we have at command, the similarity of textures impli- 
cated in this and other well-known diseases, and the results of 
clinical experience. 

In the puerperal form, when the attack comes on a few days 

* A Practical Treatise on the Diseases peculiar to Women. Phila., 1855 ; p. 445. 



ON THE DISEASES OF WOMEN. 137 

after delivery, and the symptoms are those of surgical fever, 
with pain in one or both ovaries, and violent 
ovIrk?s tmentofpuerperal constitutional disturbance, aconite and arnica 
may be given for some hours, in rapid alterna- 
tion. If not of traumatic origin, belladonna may be substituted 
for the arnica. 

The symptoms and conditions which indicate belladonna, deserve 

especial mention. It is particularly adapted to the early stage of 

peritoneal inflammation, where the pains are 

Belladonna. r . . . 1 

circumscribed and stabbing m character, or dart- 
ing, lancinating, and such as mark the acute stage of inflammation 
in other serous tissues — as, for example, in the arachnoid mem- 
brane. The diffuse peritonitis that sometimes supervenes, may 
also require the same remedy. If the attack occurs in conse- 
quence of taking cold, or is erysipelatous in character, belladonna 
is strongly indicated. The same is true of great cerebral disturb- 
ance, delirium, insomnia, dilated pupils, also of hysterical com- 
plications, neuralgia, and spasms. 

If the attack is ushered in by marked symptoms of local con- 
gestion, this remedy is particularly appropriate. This is true of 
the idiopathic, as well as of the post-partum varieties. In many 
sub-acute cases, aggravated at each menstrual period, the bella- 
donna may be given for a few hours with manifest advantage. If 
the pain is somewhat neuralgic in character, it may be equally 
useful. 

Next to belladonna, in the treatment of peritoneal ovaritis, 
colocynth, I am persuaded, is more useful than any other remedy. 
This is most marked in ovaritis supervening 
upon abortion. I am anxious that you should 
not forget this fact. In this connection it is too frequently over- 
looked. You will find the symptoms that indicate colocynth 
detailed in the materia medica. It is especially appropriate to 
those cases in which the bowels, and indeed the whole abdominal 
contents, are implicated, with stitches in the ovaries, diarrhoea, 
colic, pressure in the abdomen, suppression of the lochia, and 
tenesmus. Also in puerperal fever after vexation. Colocynth is 
recommended by some authorities for chronic ovaritis. 

The good repute of veratrum viride in puerperal metritis, its 
apparent capability of restoring the lacteal secretion and the 



138 LECTURES, CLINICAL AND DIDACTIC, 

lochia, when they have been suppressed by the inflammatory pro- 
cess, renders it probable that this agent is pos- 
sessed of some specific relation to the ovaries. 
As a remedy in ovaritis, it should be given in an early stage of the 
disease, when the organism is most perturbed by reason of vascu- 
lar and nervous derangement. 

Mercurius vivus is useful at a more advanced period, more espe- 
cially, it is said, when there is reason to apprehend that suppura- 
tion may occur. Many practitioners rely chiefly 
upon this remedy in alternation with belladonna. 
The symptoms, mostly abdominal and symptomatic, which indicate 
mercurius vivus need not be detailed in this connection. 

During the summer term of lectures in this college for the year 

1864,* I called attention to the efficacy of the hamamelis virginica 

in ovaritis. The remarkable effects of this rem- 

Hamamelis virginica. _ . . . 

edy, locally and internally, in orchitis, led me to 
infer that it would also be useful in some forms of ovaritis. I 
have prescribed it in numerous cases with remarkable results. It 
seems appropriate to the sub-acute attacks of this disease, which 
are incident to pregnancy and menstruation. In the former case, 
I have no question of its power, in some instances, to prevent 
abortion, where such a mishap threatens in consequence of ovarian 
irritation and inflammation. In the latter, it allaj^s the pain and 
averts the menstrual derangement which is so liable to follow. It 
is also useful in gonorrhceal ovaritis, in which variety the suffering 
is sometimes extreme. This affection bears a close analogy to the 
gonorrhceal orchitis of the male, in which hamamelis is almost spe- 
cific. For internal use, I prefer the second or third attenuation. 
The lauded virtues of gelseminum in gonorrhoea and sperma- 
torrhoea of male subjects, suggest that it might 

Gelseminum. . . . . 

also be useful m ovaritis. The same is true of 
its power to excite uterine muscular contractility, and to allay 
hysterical spasms. 

Lachesis is indicated in ovaritis accompanying scanty, tardy, 

irregular menstruation, vicarious leucorrhcea, and menstrual de- 

T , . rangement incident to the critical period. When 

Lachesis. 7 _ ... 

conjoined with metritis, in sub-acute and chronic 
cases, this remedy is sometimes very useful. It is recommended 

* See Medical Investigator, Vol. Ill, p. 62. 



ON THE DISEASES OF WOMEN. 139 

by Hering in chronic enlargement with induration or abscess of 
the ovaries. The following cases were kindly furnished by my 
friend, Dr. A. H. Botsford, of Grand Rapids, Michigan : 

" Miss M had suffered many months from dysmenorrhea, 

with scanty menstruation. She complained of great tenderness 
in the iliac region, sometimes on both sides, and at others only on 
one, and I remarked a fullness in the region of the ovaria, when 
felt through the abdominal walls. She was so lame and sore that 
she could not walk. The attacks would culminate in a diarrhoea, 
the discharges having all the appearance of pus. Under the use 
of lachesis she gradually improved. Indeed it never failed to 
relieve her most signally, and the early employment of it invaria- 
bly prevented the recurrence of the acute symptoms and of the 
purulent discharge by the rectum. This patient ceased to men- 
struate at twenty-seven or twenty-eight years of age, and had no 
further trouble of the kind. She died at thirty-five, of pulmonar}* 
congestion. 

" Mrs. B , aged about 35, came under my care five years 

since. Ten years ago she was ill during the whole summer, with 
pain, soreness and swelling in the region of the ovaries. Is of 
opinion that she recovered in spite of medicine. She had chronic 
diarrhoea, with stools like 'matter, as if from a boil.' She had 
also an abscess communicating with one of the intercostal cartil- 
ages on the left side of the thorax. I gave her lachesis and hama- 
melis. She was very soon relieved, and now keeps the medicine 
within reach. She has no family. Menstruation is regular, but 
she is liable to acute attacks of ovaritis with each monthly return, 
especially if she overworks or is much fatigued." 

In frail, scrofulous subjects, predisposed to excessive purulent 
discharges, these ovarian abscesses sometimes secrete an enormous 
amount, and for a long time. This drain produces a species of 
cachexia in which other remedies may also be of service. The 
hepar sulphuris, calcarea carbonica, china, and phosphoric acid 
have been recommended to meet this indication. 

Bryonia does not appear to be so well adapted to inflammation 

of the peritoneum as to that of some other serous tissues — as, for 

example, the pleura and synovial membrane?. 

Bryonia alba. . - ' r -\ 

So far as we are aware, it has no specinc rela- 
tion to the ovary. In the puerperal form of ovaritis, where the 



140 LECTURES, CLINICAL AND DIDACTIC, 

attack sets in with chilliness and rigors, and especially in case of 
threatened mammary abscess, the breast being large, hard, tense 
and painful, it may, however, be very useful as an intercurrent 
remedy. We have sometimes employed it with advantage in 
rheumatic ovaritis. The same remarks apply to the rhus toxico- 
dendron and the cimicifuga or macrotys. 

The ovular theory of menstruation is confirmed by clinical 

experience. Excepting those already named, and a few others 

which are given for specific reasons, all the 

The menstrual disorder • -i -i i • 

aids m choice of the rem- remedies ot considerable repute, m the treat- 
ment of sub-acute and chronic ovaritis, have 
been prescribed for the relief of menstrual irregularities. More- 
over, it is especially significant that each of these remedies is said 
to have caused abortion, a fact which confirms the idea advanced 
by Tyler Smith, that the specific stimulus of uterine contraction 
resides in, or must operate through, the ovaries. From these 
observations, certain therapeutical deductions are obvious. There 
is no question but that many examples of ovaritis, complicated 
with catamenial derangement, have been unwittingly cured by 
secale cornutum, sabina, apis mellifica, pulsatilla, sepia, platina, 
cantharis, and caulophyllin. The best criteria for the use of these 
remedies in ovaritis, will be found in their adaptation to menstrual 
disorders, as amenorrhcea, dysmenorrhcea, menorrhagia, and also,, 
in many cases, to leucorrhcea. 

Ovaritis, complicated with ulceration of the os uteri, requires 
to be treated most carefully. A resort to astringent injections, or 
cauterization, is too frequently had, by those who covet notoriety* 
and are reckless of consequences. The proper constitutional and 
local treatment for uterine ulceration will be detailed in a subse- 
quent lecture. 

For atrophy and induration of the ovaries, with which sterility 
is almost always associated, jodium, conium, plumbum and baryta 
muriatica, are in good repute. Change of air, 
JoX m *ndinL^ an <* diet, travel and diversity of scenery, are 
sometimes of lasting benefit. I have succeeded 
in curing one case of barrenness, in which there was chronic indu- 
ration and insensibility of both ovaries, with an almost total atre- 
sia of the canal of the uterine cervix. This canal was dilated 
artificially, while, at the same time, remedies were given to restore 



ON THE DISEASES OF WOMEN. 141 

the menstrual process. Conception followed, and the ovarian lesion 
disappeared. 

When there is reason to suspect that either the gonorrhceal or 

syphilitic taint is present, the mercurius solubil- 

ovIrkS mentforgonorrhoeal is > mercurius jodatus, nitric acid, thuja, kali 

jodatum, or aurummetallicum, may be indicated. 

The curative virtue of calendula would be available in case of 

fistulous opening and discharge of the ovarian 

abscess through the abdominal walls, or into the 

bowel, bladder, uterus, or vagina. 

In puerperal ovaritis, when the inflammation and tenderness 

become diffuse and very acute, I know of no local expedient so 

grateful and beneficial, in a majority of cases, 

Local treatment. 1 ,.. n -. n1 

as the application 01 dry, hot bran to the abdo- 
men. It should be sewed up in bags, heated as hot as can be 
borne, applied, and then renewed frequently. This application 
possesses the merit of availability and lightness ; it is inodorous, 
and medically unobjectionable. 

After the acute symptoms have yielded somewhat, and the 
patient is able to lie upon her side, dry heat may still be used, by 
means of a heated dinner plate, which is wrapt in flannel and 
kept in constant contact with the abdominal parietes. Cloths 
dipped in hot water soon become cold, and the patient may be 
chilled thereby. Hops are sometimes prescribed in extreme cases, 
in which it is impossible for the patient to sleep, and where nerv- 
ous symptoms predominate. Emollient cataplasms of various kinds 
have been resorted to, and sometimes with good results. 

In acute ovaritis, where the pain is more circumscribed and very 

severe, arising, propably, as M. Velpeau suggests is the case in 

orchitis, from strangulation of the organ by its 

Hamamelis virginica. _ . - , „„ , , . . 

envelop, great relief may be afforded by the 
external use of the hamamelis virginica. I prefer Halsey's fluid 
extract of this drug, which may be mixed with hot water, in the 
proportion of one part to three, and applied locally, b}' means of 
cloths or flannels that have been dipped therein. In case the 
swollen and sensitive organ is prolapsed along the wall of the 
vagina, a weaker solution of the hamamelis, containing glycerine, 
may be used as a vaginal injection, or applied by means of cotton 
wool or charpie saturated with the same, and introduced into the 



142 LECTURES, CLINICAL AND DIDACTIC, 

vagina. This application is sometimes remarkably efficacious. It 
may also be injected into the rectum. If the 

Arnica — Aconite. . _ . . „ . . . 

inflammation is 01 traumatic origin, arnica may 
be used in the same manner as recommended for the hamamelis. 
The local and general employment of aconite is recommended in 
case of a rheumatic complication, which sometimes involves the 
most extreme suffering. 

Vicissitudes of weather and temperature sometimes affect this 
class of cases so unfavorably, that it is well to protect and insulate 
the ovaries from their harmful influence. For 
dam^S fr ° m coM and * n * s P ur P°se a layer of cotton batting, flannel, 
or silk, should be worn next the abdomen. In 
very susceptible subjects, where, from taking cold, mild attacks of 
ovaritis frequently accompany menstruation, this expedient is also 
serviceable. 

Warm baths are better than cold, and the hip bath is preferable 
to any other. The cold hip bath is sometimes useful, but should 
be taken quickly, in order to insure reaction. 
They should not be used indiscriminately. For 
the relief of pelvic pains incident to severe attacks of ovaritis and 
ovarian neuralgia, Dr. Aran recommends the expedient of packing 
the speculum, in vagina, with coarsely powdered ice. Such ex- 
treme measures are rarely, if ever, justifiable. 

Little attention need be paid to restoring the displaced ovary. 
Remove the inflammation, and the structural changes consequent 
upon it, and the dislocated ovary will take care of itself. Any 
attempt to reduce the luxation, farther than by placing the patient 
in a favorable position, would probably result in more of harm than 
of good. 

As one of the most trying obstacles in the way of a cure is found 

in the recurrent menstrual congestion ; so it is quite impossible, 

in many cases of ovaritis, to effect a cure while 

jwribe sexual inter- the patient yields to seX ual indulgence . She 

must live absque marito. I have found that 
those patients with ovaritis who come to this city for treatment, 
and who are thus removed for a time from the stimulus of sexual 
excitement, recover more rapidly and permanently than others of 
my patients, who, while being treated, are obliged to remain at 
home. There are, however, a few exceptions to this rule. 



ON THE DISEASES OF WOMEN. 143 



LECTURE VIII. 

bilious colic during pregnancy. 

Gentlemen : 

We will devote the first part of this hour to the study of a case 
of bilious colic in a woman who is pregnant. 

Case. — Mrs. D , aged 30, a healthy looking woman of. bil- 
ious temperament, with black hair and eyes, is six months ad- 
vanced in her third pregnancy. She complains of repeated attacks 
of bilious colic, which are accompanied by the usual symptoms of 
that disorder. Sometimes the paroxysm is very acute, and of brief 
duration, coming on abruptly and going off in the same manner. 
Again, the pain is more dull, steady, and persistent, lasting per- 
haps for twelve hours or more. These paroxysms are not refera- 
ble to errors in diet, or to excess of exposure, labor or worry, as 
in ordinary bilious colic, but recur without any obvious cause, 
sometimes waking her out of a sound sleep. She had them 
throughout both of her former pregnancies, but never at any 
other time. She carried both of her children to term. Unless 
they have continued for six hours or more, the attacks of pain are 
not followed by jaundice. Her father and two of her uncles were 
subject to severe fits of bilious colic. 

This case illustrates the peculiar relation existing between the 

uterus and the liver, — a subject of study which is really more 

important than you may have supposed. For, 

The vascular relation be- 1 . ,, , , 

tween the uterus and the not only are these viscera organically related 
through the sympathetic and spinal nervous 
systems, but their vascular connections also are peculiar and sig- 
nificant. 

The portal vein receives blood from each and all of the chylo- 
poietic organs. Without this supply of blood from the stomach. 
the intestines, the spleen, the pancreas, and the mesentery, the 
curious and complex function of the liver could not bo properly 
performed. But this is not all. The vaginal, hemorrhoidal, ut erine, 
and ovarian plexuses of veins also communicate, by anastomoses. 



144 LECTURES, CLINICAL AND DIDACTIC, 

with the portal system, as well as with the inferior vena cava. A 
portion of the return current of blood is therefore conveyed 
directly from the pelvic organs to the liver, en route for the gen- 
eral circulation. 

Whether this vascular arrangement really implies such a com- 
pensatory relation between the hepatic and uterine functions as 
was insisted upon by Stahl and others, it is foreign to our present 
purpose to inquire. Its very existence suggests the possibility of 
diseased conditions which shall depend upon some derangement of 
the circulation in these inter-communicating vessels. 

One of the most marked of the anatomical changes consequent 
upon conception is found in the uterine veins. They become en- 
larged into canals and sinuses, with an increase 
grrv a i S d C ute r ru C s han§es " the °^ ca P ac ity which is in ratio with the nutri- 
tive demands of the contained embryo or foetus. 
Being destitute of valves, the only safeguard against a regurgita- 
tion and stasis of blood in them is their tortuosity, and perhaps, 
also, as Kollicker has shown, the temporary supply of muscular 
fibres to their middle coats. 

A woman becomes pregnant. Prior to this she may have been 
very healthy. She may or may not be of a bilious temperament. 
But within the month, and sometimes almost 
prSnancy ymptoinsinearly immediately, the hepatic and intestinal func- 
tions are deranged. She has nausea and vom- 
iting, which, as in bilious affections uncomplicated with gesta- 
tion, are worse in the morning. The tongue is furred, the breath 
foul. She has no appetite for breakfast, there is disgust of water, 
almost invariably constipation, with bilious headache, highly-col- 
ored urine, and hypochondriasis. The matter vomited consists 
chiefly of mucus, but the paroxysm does not terminate until more 
or less of bile, it may be only a few drops, is ejected. 

These symptoms are commonly known as " bilious." That they 
are contingent upon pregnancy is a matter of every-day observa- 
tion. But that the extraordinary development 
^The uterus a divenku- of the vascu i ar system of the uterus consequent 
upon conception is their indirect cause, is not so 
generally recognized. This functional derangement of the liver 
may arise from sluggishness of the venous circulation in the pel- 
The uterus becomes a diverticulum which receives 



ON THE DISEASES OF WOMEN. 145 

and retains an unusual quantity of venous blood. Its weight is 
increased, it suffers a temporary prolapse, pressure therefrom in- 
creases the obstruction in the local circulation, and the parts which 
are even remotely related through a common vascular apparatus 
are almost necessarily implicated. 

A similar result may happen in the case of uterine deviations 
of whatever kind, but more especially in prolapsus, procidentia, 
and retroversion, in uterine scirrhus, fibroids, 
utSne a S ffecfion g s! ment in or P 0l ypi > m chronic metritis, dysmenorrhea, 
amenorrhea, and uterine ulceration. As hem- 
orrhoids and dysentery, and similar diseases in the ano-pelvic 
region, are very liable to be complicated with some hepatic dis- 
turbance, so it is with these different lesions of the womb. And 
since a proper supply of bile is indispensable to intestinal diges- 
tion, we see at a glance what a blow is aimed at nutrition when 
the function of the liver is thus deranged. In this list of diseases 
there is not one which is not usually accompanied by more or less 
of indigestion and inanition. 

Now the chief office of the liver, as an excretory organ, is to 

■eliminate the cholesterin, which results from the destructive 

changes going on in the nervous substance or 

Cholestraemia contingent . . . 

iipon pregnancy and uter- neUTUie. ThlS DOSt-OrganiC product WOUld be 
ine disease. „ , , . . 

poisonous if retained in the blood, and it is 
therefore expelled by way of the hepatic and intestinal outlet, just 
as urea escapes through the urinary apparatus. And, as we ob- 
serve that the muscular tissue, of which it was so recently an 
integral part, is peculiarly susceptible to the toxical effects of an 
excess of urea in the blood, so the nerve-centers, the brain espe- 
cially, are extremely sensitive to the action of cholesterin. Hence 
the hypochondriasis of pregnancy, and of most chronic uterine 
affections, which owes its origin to torpidity of the liver, and to 
the imperfect performance of its excretory function. And hence, 
also, the possibility of such suffering as that of which our patient 
complains. For biliary calculi consist chiefly of cholesterin, and 
their existence in a given case is proof positive of hepatic derange- 
ment. 

Bilious colic is therefore a contingent of pregnancy. There are 
those who, like Mrs. D., never have it except when they are preg- 
nant. Some, however, are liable to it whenever they menstruate * 

IO 



146 LECTURES, CLINICAL AND DIDACTIC, 

others in consequence of excessive sexual intercourse or excite- 
ment , and I have known it to be caused by wearing an ill- 
adjusted or a misplaced pessary. 

Treatment. — We have proof that a knowledge of the organic 
relations between the uterus and the liver is practically import- 
ant, not only in the clinical history of similar 

Common influence of , .. . , , > n 

remedies on the uterus cases, but also in the known common influence 
of different remedies over these organs. Take, 
for example, nux vomica, aloes, podophyllin, and chamomilla, as 
they are most frequently prescribed in uterine and intra-pelvic 
affections generally. The symptoms which guide to the selection 
of any of these remedies usually pertain to the liver, or to some 
portion of the intestinal tract, rather than to the uterus and its 
appendages. 

There are, it is true, many exceptions to this rule, but the clini- 
cal fact is suggestive. In uterine lesions especially, the dial-plate 
upon which their characteristic symptoms may 

The symptoms of uterine .. 1 -. -1,-1-ip 

disorder may be remotely be read, and which must be consulted betore 
we can treat them under standingly and success- 
fully, is often located Avhere you would least suspect it, — some- 
times in the liver, or in some portion of the gastro-intestinal tract ; 
again in the heart, the brain, or the general nervous system, and 
even in the eye. Hence a great variety of remedies may be 
requisite in uterine therapeutics, and the necessity of careful 
study in their employment must be apparent to you all. 

Before the termination of pregnancy, and while the cause is still 
in operation, we should be chary of promising a radical cure in a 
case of this kind. The disease beine self-lim- 



de- if-prl if,a svmnfnms rna.v nnf, w"hnllv 

rangement self-limited 



This form of bilious de- jfced, its symptoms may not wholly disappear 



until term. In exceptional cases, however, 
there may be but one or two attacks of the colic. During the 
paroxysm the indication is to afford prompt relief from the suffer- 
ing. Amonsr the remedies most frequently 

Remedies during the fit. ■,•','«,. 

employed for this purpose are nux vomica, 

podophyllin, chamomilla, atropine, and chelidonium. With some 

practitioners the dioscorea is in excellent repute. Inhalations of 

, ether or of chloroform may be iustiflable in eX- 

Local palliatives. ° ° 

treme cases. In hysterical subjects, with threat- 
ening spasms, ignatia, belladonna, or hyoscyamus may be called 



ON THE DISEASES OF WOMEN. 147 

for. Dry heat, in the form of hot plates wrapped in flannel, or 
bottles of hot water, or cloths wrung out in hot water and applied 
over the seat of the pain, are sometimes most grateful and bene- 
ficial. The warm bath is contra-indicated in case of bilious colic 
occurring in a pregnant woman. 

China is perhaps the best prophylactic against bilious colic. It 
seems to hold some specific relation to the formation and excre- 
tion of cholesterin. We do not know precisely 

Prophylaxis. 

what that relation is. Whether it stops the 
destructive metamorphosis of neurine, and thus limits the produc- 
tion of cholesterin, or helps the liver to eliminate it more readily, 
is an unsettled question. At all events, we may avail ourselves 
of the clinical fact that it serves to palliate and to prevent painful 
attacks of this disorder. When prescribed with this intent it 
should be given once or twice daily. In a case like the one before 
us, china will not interfere with gestation. Mrs. D. will take this 
remedy morning and evening. 

Her diet should consist of albuminous substances, and fruits. 

Fats, and all kinds of pastry, would be poison- 
piet: mental and physi- ous# j^e same i s true of coffee and malt 

cal exercise. 

liquors. She should have daily exercise in the 
open air, and be especially careful to avoid all sources of mental 
anxiety. 

PROLAPSUS UTERI, WITH SUPERFICIAL ULCERATION OF CERVIX. 

Case. — Mrs. , aged 24, began to menstruate at twelve, 

from which period she dates her illness. The catamenia are 
irregular, sometimes appearing once in three weeks, again in four, 
and, occasionally, with an interval of five weeks. The only par- 
ticular suffering experienced at the period is a dull, aching pain 
about and in front of the left hip, and a dragging pain across the 
loins. The flow usually continues three days, and is normal in 
quantity and quality. 

During the inter-menstrual period she complains of a bearing- 
down sensation within the pelvis. There is great weakness of the 
back in the lumbar and sacral regions. Standing for any length 
of time, or walking a short distance, fatigues her exceedingly. 
When weary, she is subject to a peculiar sensation in the lumbar 
region, " as if a considerable portion of the back-bone, perhaps 
six inches long, had been removed." This is soon followed by a 
faint feeling, and sometimes by actual syncope. At other times. 



148 LECTUKES, CLINICAL AND DIDACTIC, 

and especially if she is in a room in which there are many other per- 
sons, as in a church, or in a concert hall, there is a sense of im- 
pending suffocation. Sometimes the unnatural feeling along the 
spine recurs without any apparent cause or premonition. Then 
follows an irresistible propensity "to drop down upon the knees.'* 
At such times the lower limbs feel numb, insensible, and semi- 
paralyzed, but the knees are especially weak and powerless. 

Another symptom which she has remarked is a sense of cold- 
ness on the top of the head, which, whenever she swallows either 
warm or cold drinks, is curiously changed into a sensation as of 
" crawling " under the scalp. So marked is this symptom that 
she has insensibly acquired the habit of placing her hand on that 
part of the head for its relief, whenever she puts a cup or a glass 
to her lips. 

For some years past (she does not know how long) she has had 
leucorrhcea. The discharge is habitually more profuse immedi- 
ately before, but ceases during menstruation. In character she 
describes it as "catarrhal," creamy, bland, and unirritating. 

The touch reveals, the uterus prolapsed, the neck of the womb 
tender and tumefied. When she stands the anterior lip of the 
cervix rests upon the posterior vaginal wall, directly over the 
perineum. Upon examination with the speculum, a large, irreg- 
ular, suppurating ulcer was found to extend within the external 
os uteri, and over a considerable portion of the anterior lip of the 
cervix. 

Uterine deviations not unfrequently date from puberty. They 
are the more likely to follow if menstruation begins at a very 

early or a very late age. With this patient the 
beginat n puberty 0ns may flow first appeared when she was but twelve 

years old. Under these circumstances it must 
have required more than ordinary effort on the part of the ova- 
ries and the generative intestine to establish this very important 
function. The ripening, transit, and parturition of the ovum in 
such subjects resembles labor, and so far as disorders of place are 
concerned, the consequences to the uterus are of a similar char- 
acter to those which are contingent upon that process in older 
women. In the case before you, the afflux of blood to the inter- 
nal generative organs, the increased weight of the womb, the 
requisite dilatation and relaxation of the uterine cervix and of the 
vagina, the contractile effort of the womb to expel its contents, 
supplied the identical conditions which predispose to uterine dis- 
placements following abortion or labor at term. 



ON THE DISEASES OE WOMEN. liO 

Irregular menstruation may be a cause or a consequence of 
uterine deviations. In one form or another they are very apt to 
co-exist. It is unusual to meet with a chronic 
caSf pr r okpsus ruation a case °f prolapsus, or of retroversion, in which 
the menses are not more or less irregular as to 
the time and method of their recurrence. This state of things is 
undoubtedly due to a derangement in the local, intra-pelvic cir- 
culation. The uterus has become the seat of venous engorge- 
ment. Its increased weight has borne it down upon the structures 
that were designed to sustain it, until they have given way, and 
it has become displaced. For the uterine ligaments are not forti- 
fied against this increase of weight in the womb. An undue or 
unusual determination of blood to this organ, or sluggishness in 
its circulation, weakens these supports, and renders them more 
liable to yield. 

Hence, also, the frequent complications of uterine displace- 
ments with chronic disorders of digestion. The connection be- 
tween the venous systems of the uterus and the 
diSstiteVS^rs 5 and liver, explained in my remarks upon the pre- 
ceding case is significant. There are few ex- 
amples of prolapsus which are not accompanied by haemorrhoids, 
prolapse of the rectum, or by a more or less obstinate constipation. 
Lumbar and sacral pains are incident to most cases of prolap- 
sus, and of uterine ulceration also. But the kind and degree of 
these pains are modified according to circum- 

Lumbar and sacral pains. 

stances. As a rule, they are more acute and 
tormenting in nervous, hysterical and delicate women than in 
those who are of a different temperament and organization. 
Among the more robust and energetic there is sometimes a re- 
markable tolerance of uterine displacements, which may exist for 
years with little complaint of pain in the loins, or of especial suf- 
fering of any kind. But these cases are exceptional. 

In prolapsus, the pains in the lumbar and sacral regions are 
brought on or increased by standing, riding, or walking, and 
sometimes by bending forwards and then rising suddenly to an 
upright position. The back feels very weak, and perhaps as 
though it were actually broken in two. The more chronic the 
case the greater the suffering, more especially if at the same time 
the patient has leucorrhcea, irregular menstruation, or ulceration 



150 LECTURES. CLINICAL AND DIDACTIC, 

of the uterine cervix. For, independently of the falling of the 
womb, these several diseases are almost always accompanied by 
similar symptoms. This poor woman has them all, and it is by 
no means strange that such an array of symptoms should present 
themselves. 

The dropping down of the uterus, and its direct pressure upon 

the anterior sacral nerves, and also upon the utero-cervical ganglia 

of the sympathetic, is sufficient to account for 

Prolapsus and paralysis. ^ • -i i -i • 

the sudden, partial, and temporary paraplegia, 
or powerlessness in the lower limbs. She falls upon the knees 
irresistibly. There is numbness and semi-paralysis, which are 
self-limited. The nervous currents between the spinal center 
and these parts are interrupted, and the consequence is manifest. 
Rest, with change from the upright to the horizontal position, 
causes the womb to lift itself, as the French would say, and the 
normal nervous circulation returns. 

The same physiological reasons explain the peculiar sensation 
" as if a portion of the spine had been removed," the faintness, 

the syncope, and the eccentric symptoms which 

are referred to the top of the head. Through 
the frequent recurrence of this displacement, the nervous system 
has acquired a predisposition to hysterical complications. On 
this theory, the increase of suffering from swallowing cold or 
warm drinks, which act produces a " crawling " sensation beneath 
the scalp, as well as the sense of suffocation when in a room full 
of people, are by no means inexplicable. The relief afforded by 
pressure upon the top of the head, proves that the peculiar sensa- 
tion felt in that region is purely nervous. 

Let me remind you, however, that these symptoms are none 
the less real because we style them " nervous," and because it is 

only through our knowledge of the reflex nerv- 
S yrnp?o r rns! ItyofUnervous ' ous system that we are competent to explain 

their existence. In truth, this woman has suf- 
fered more from these peculiar sensations in the head than from 
the pains in the loins, or in the left iliac region, the temporary 
paralysis, or from any and all of her other symptoms. For, al- 
though the element of exaggeration enters largely into the hys- 
terical constitution, we cannot doubt that persons with this 
temperament are possessed of an increased susceptibility to pain 



ON THE DISEASES OF WOMEN. 151 

and disease, and that they do really suffer more than others under 
similar external circumstances. 

But this case has other complications. Some authors will tell 

you that prolapsus, leucorrhoea, and uterine ulceration, like a 

cough or a diarrhoea, are not to be considered 

Symptoms versus disease. 

as so many separate disorders, but as symptom* 
merely. And in the main their view is correct : but symptoms, 
like quarrels, do not come without cause. When it is possible, 
we must find out their source, in order to be able to explain their 
significance and to cure them. There may have been an order of 
sequence in the coming on of these symptoms, which it is most 
desirable and necessary for the physician to know. 

Our patient has a chronic prolapse of the womb, which in all 
probability owes its origin to causes already named. Following 

this displacement, and consequent upon it, she 
Leucorrhoea and uicera- a i so h as leucorrhoea and uterine ulceration. 

tion from prolapsus. 

Which of these two contingent affections came 
first, we do not know. Nothing is more common than a leucor- 
rhceal flow of a catarrhal nature accompanying the slighter and 
more temporary degrees of uterine prolapse. Here the discharge 
depends on glandular derangement without structural lesion. 
There need be, and generally is, in these cases, no ulceration 
whatever. 

But if the uterine deviation is persistent, and especially if the 
uterus lies low upon the perineum, its friction against the poster- 
ior vaginal wall is pretty certain, sooner or 

Ulceration from abrasion. ,./,..... 

later, to cause an abrasion 01 its investing 
epithelium. This mechanical cause may induce and perpetuate 
a superficial ulceration of the neck of the womb, or of the vagina, 
or of both of these parts together. As the deeper seated textures 
become involved in the lesion, a more or less copious discharge 
is poured out, and in future the leucorrhoea will either depend 
entirely on, or be greatly modified by, the existing ulceration. 

The belief is very general that, directly or indirectly, all cases 
of uterine ulceration originate in the inflammatory process. But 

I apprehend this view is not correct. Inflam- 
madon!: ation **** inflam ~ nation always imperils the proper nutrition of 

the or^an or tissue in which it is seated. It> 
chief danger lies in this very fact. But there are many disorders 



152 LECTURES, CLERICAL A^D DIDACTIC, 

of nutrition, and some of them of a most serious character, which 
certainly are not in any manner dependent upon the inflammatory 
process. 

It is probable that a large proportion of cases of uterine ulcer- 
ation commence with simple abrasion of the mucous surface. 
The wearing of an ill-adjusted pessary, or of 
sicm auses ° f uterine abra " one which is made of improper material , the 
careless employment of the female syringe ; the 
abuse of sexual intercourse ; horseback riding ; mechanical 
injury of the os uteri during delivery ; the use of harmful injec- 
tions thrown into the vagina, especially after coitus or during' 
menstruation ; the contact of corrosive discharges from the 
uterine cervix, and of vitiated semen, as well as friction from 
the various uterine displacements, may be sufficient to produce it. 
Superficial ulceration of the os following abrasion of its epithe- 
lium differs from other varieties of uterine 
from at abr e asio f n ulceratl0H ulceration. It consists essentially in defective 
reparation of its investing membrane, and not 
in a destructive metamorphosis of the underlying textures. 

Treatment. — The medical management of such cases as this is 

especially vexatious. "We must begin rightly or we shall fail. 

Any attempt to cure the leucorrhcea without 

Therapeutical reflections. . . 

recognizing or relieving the ulceration ot the 
os uteri, or to remedy this lesion without doing anything for the 
displacement of the womb, would reflect upon our skill and 
experience. And so also if we were to elevate some of the inci- 
dental, irrelevant, hysterical symptoms of which our patient com- 
plains to the dignity of characteristic symptoms, when they do 
not deserve such distinction, and afterwards busy ourselves with 
curing them. 

It is a rule in therapeutics that the symptoms of a complicated,, 
chronic case of disease should be made to disappear in an order 
which is the reverse of that in which they came 
or?e U rofs d y e m P to b rn e s. from — the last first, and so back to the starting- 
point. But when applied to the treatment of 
uterine affections, this rule has many exceptions. The most 
stupid blunders have sometimes been perpetrated through ignor- 
ance of this fact. 

The first indication is to keep this woman as quiet as possible- 



ON THE DISEASES OF WOMEN. 153 

She need not lie in bed all the time, but she should assume the 
recumbent position either upon the side or the 

Postural treatment. 

back. And, it necessary, she should persevere 
in this for some weeks, or even for months. For you will not 
cure these cases so promptly as some enthusiasts would lead you 
to believe possible. Walking, standing and sitting aggravate her 
sufferings. She must, therefore, keep quiet. 

Her shopping and her church-going must be done by proxy. 
She is no more able to run a sewing machine than she is to run 

with a fire engine. And, if she were my pri- 

Dressing the hair, etc. . . n 

vate patient, 1 should forbid her dressing her 
own hair — which is really one of the most tiresome and injurious 
kinds of exercise for a woman who is suffering from uterine dis- 
ease. Her clothing should be worn loosely about the waist. 

No matter what the kind and degree of the uterine displace- 
ment, if the os uteri is abraded or ulcerated, it is wrong to apply 
any pessary whatever ; for, by direct pressure 
centra-indications for U p 0n an d contact with, the denuded surface, 

the pessary. J. ' 7 

these instruments may work serious mischief. 
Under such circumstances, they have been known to increase the 
suffering, to extend the lesion of the cervix, to multiply the reflex 
symptoms, and to augment the leucorrhoeal flow. Keeping the 
patient in the proper position is a harmless and efficient substi- 
tute for these appliances in all cases of this particular kind, 
(JExit the patient?) 

Another requisite for this woman's recovery, of which I have 
forborne to speak in her presence, is the prohibition of sexual con- 
gress. Otherwise it is next to impossible to 
Prohibition of sexual cure some f these cases. Her separation from 

congress. - 1 - 

her husband will insure against the undue 
determination of blood to the internal generative organs, which 
is consequent upon the sexual act, and will thereby remove one 
of the principal causes that serve to perpetuate the abnormal con- 
dition and position of the womb. If we overlook or ignore this 
item, a cause which may counterbalance all our efforts at cure, 
will be constantly at work, and we may fail in consequence. 

I do not doubt that much of the boasted efficacy of escharotics 
in uterine ulceration should really be attributed to the interrup- 
tion of sexual intercourse, which they necessitate. I can conceive 



154 LECTUEES, CLINICAL AND DIDACTIC. 

that frequently the caustic might be less harmful than coitus. 

And so, also, of similar cures which are ascrib- 

_ Modus operandi of caus- e( q to the use of cold water in the various hydro- 
tics, etc., in certain cases. J 

pathic establishments. Without saying a word 
against this system of treatment, it is quite probable that the ben- 
efit derived in many of these cases is due as much to the enforced 
absence of the patient from the bed and board of her husband as 
to the baths and remedies that are prescribed. 

For the cure of a simple, suppurating ulcer of the os uteri, I 

know of nothing so beneficial locally as the calendula. To a 

drachm of the strong tincture of calendula add 

Calendula topically. . 

two ounces each 01 glycerine and distilled 
water. Of this mixture a tablespoonful may be put into a tea- 
cupful of tepid water for an injection per vaginam. This injec- 
tion, which should be retained as long as possible, may be repeated 
once or twice daily. The calendula not only heals the abraded 
surface most kindly, but it also relieves the swelling and tender- 
ness of the cervix, which are so marked in the case under review. 
In not a few instances it may suffice to arrest the leucorrhceal flow. 
Or a mixture of glycerine and water in equal parts may be 
applied by means of a cotton tampon. If you think best, there 

is no valid objection to adding a few drops of 

Other local expedients. tit.. . 

the hydrastis to this preparation. I have some- 
times melted simple cerate and applied it directly to the denuded 
cervix, through the speculum, by means of a camel's hair pencil. 
Injections of sugar and water are wonderfully efficacious in heal- 
ing these simple abrasions of the utero-vaginal mucous membrane. 
The preparation of collodion with castor oil, recently extolled by 
M. Latour, in his method of treating diseases by isolation, has 
been of great service to some of my private patients, in whose 
cases it was applied to the os uteri, in the same manner as recom- 
mended for the simple cerate. 

The internal remedies most appropriate for the case under con- 
sideration are mix vomica and calcarea carbonica. I need not 
detail their respective indications. If you will study the symp- 
toms carefully, excluding those which are merely sensational and 
incidental, you will not fail to endorse my prescription. They 
should be given, for a limited period, night and morning — the 
mix at night and the calcarea in the morning. Let her report at 
the end of a week. 



ON THE DISEASES OF WOMEN. 155 



PRURITUS OF THE VULVA. 



Case. — Mrs. , a healthy looking woman, has an infant of 

three months, which is her third child. She says that when the 
babe was a month old she began to suffer from an itching of the 
external genitals. At times this itching is almost insupportable, 
and she really feels as if she might become insane in consequence 
of it. She describes it as worse at evening, after being much up- 
on her feet during the day. There is a mucous secretion from 
the vagina which is sometimes quite copious, but generally scanty, 
and which she has observed is very apt to dry upon the parts 
exposed to the air, where it forms into scales that are easily de- 
tached hy rubbing. Urination is sometimes followed by scalding 
and burning sensations, which are referred to the vulva rather 
than to the urethra. Coitus is painful, and apt to be succeeded 
by a pinkish discharge from the vulvo-vaginal canal. She had 
this local trouble while nursing both her former children, with 
the last of which it continued for more than a year. Her skin is 
fair, and to her knowledge she has never had any eruption. The 
babe is well, and thrives upon the breast exclusively. 

This form of prurigo usually depends upon inflammation of 
some portion of the mucous membrane lining the vulva. It is in- 
cident both to the purulent and the follicular 

Various causes. -i • • • • • 

forms of vulvitis, ol which pruritus is the most 
distressing symptom. Among the causes which may induce it 
are, a lack of cleanliness ; the contact of acrid vaginal secretions, 
as in leucorrhcea, uterine cancer, etc. ; masturbation ; gonorrhoea ; 
syphilis ; vegetative growths ; ascarides , indigestion ; diabetes ; 
and the use of alcoholic drinks or highly seasoned food. Some- 
times it is caused by acrid vaginal discharges poured out during 
pregnancy, and may result in abortion. Again, it is developed 
during lactation, and will not cease entirely until the child is 
weaned. In little girls it may accompany the exanthemata, and 
disappear with them. In women, it sometimes alternates with a 
chronic eruption to which they have been subject. In very nerv- 
ous persons, it may possibly arise from simple hypenesthesia of 
the mucous membrane. There may be aphthous ulceration, or 
perhaps an herpetic or eczematous eruption, or an abrasion at the 
junction of the mucous membrane with the skin, which shall be 
sufficient to account for the suffering. Not unfrequeiitlv the sur- 



15(5 LECTURES, CLINICAL AND DIDACTIC, 

face is so heated and inflamed that the mucus secreted is dried 
upon the parts, and this causes such intolerable itching that, no 
matter where she is, or what her surroundings, the patient can- 
not refrain from rubbing or scratching. Another cause of this 
troublesome affection in certain cases is disease of the uterine cer- 
vix. Some attacks of pruritus pudendi have been attributed to a 
varicose condition of the veins of the vagina. Others are known 
to arise from the presence either of a peculiar parasite (pediculus 
pubis), or of the itch insect (acarus scabiei), in the hairy portion 
of the mons veneris. 

Dr. Meigs reports the following case :* 

" I was consulted for a young lady about twenty years of age, 
who suffered from an intolerable pruritus and uneasiness of the 

vulva. Her physician had prescribed many and 
^Pruritus from trichiasis. y ar i ous remedies in vain. He had examined, 

by inspection, the privities, but could not dis- 
cover the cause ; which, however, was not dissipated by his appli- 
cation of nitrate of silver and other medicines. When I was 
called to give my opinion of the case, I was much surprised to find 
it attributable to a real trichiasis of the vulva. The hairs that 
grow usually on the derma, and then not very close to the epithe- 
lial surface, had sprung from the very margin of the mucous mem- 
brane of each labium. They were straight, like eyelashes, and 
pointed inwards. It was from the tickling and pricking of the 
points of these hairs that her distress arose. . They were all re- 
moved by her nurse, with tweezers, and the complaint disap- 
peared." 

The itching, burning or stinging sensation, whichever it may 
be, is not always constant, but remits and intermits. It may be 

aggravated by exercise, fatigue, excessive heat 

of the weather, standing before a fire, by the 
warmth of the bed, by mental emotion, passional excitement, or 
urination. It may be worse at evening and at night, thus pre- 
venting rest and sleep. Sometimes the patient is compelled to 
leave her bed and walk about the room in order to obtain 
the least respite from her suffering. It worries her into a nervous 
state, rendering her unhappy, petulant and ill. The paroxysms 
may be so severe as almost to drive her crazy. Sometimes 

* Woman : her Diseases and Remedies, etc. Phila., 1S59 ; p. 96. 



OX THE DISEASES OF WOMEN. 157 

they give rise to local spasm in the form of vaginismus, or in a 
more general way to an hysterical fit. In the mildest variety the 
cutaneous surface of the larger labia is the seat of formication, or 
crawling sensations, which torture the patient exceedingly. In 
this case she will insist that multitudes of little insects are run- 
ning over the external generative organs. When the mucous 
membrane reflected over the clitoris is the seat of the itching, 
the case develops into one of nymphomania. 

The scratching and rubbing of the parts really affords but little 
permanent relief, and yet it is impossible for the poor victim to 
resist such a propensity. In this manner the 
wounds'* from self_inflicted surface is sometimes so severely wounded that 
extensive injury is done to the soft tissues. In 
case there is an eruption, the vesiculse are broken and the nails 
may cause extensive abrasions and ulceration. Sometimes the sen- 
sation of heat in the parts affected is even worse than the itching. 
In some women the attack precedes the menstrual flow. The 
physiological determination of blood to the pelvic viscera, and 
the irritable condition of the vulvo-vaginal 
s tr^ai y p P eHod de the men " glands and nerves, which usher in the "pe- 
riod," seem sufficient to account for this result. 
These persons become exceedingly nervous, and suffer greatly at 
such times. They are on the eve of an hysterical paroxysm, it 
may be for hours together ; fitful, capricious, disheartened, and 
sometimes almost demoralized. When the flow commences the 
crisis is soon past, and the pruritus may not return during the 
month. In such cases the proper menstrual flow is often supple- 
mented by a copious leucorrhceal discharge. The most intract- 
able examples of neuralgic and spasmodic 
Pruritus with dysmenor- dysmenorrhea mav originate in this form of 

xncea and amenorrhcea. J J o 

pruritus. Sometimes the pruritus comes on for 
a few nights after the cessation of the flow at each period. Or 
it may be due to menstrual suppression, constituting the prurigo 

latens of Alibert. The liability to this painful 
^Pruritus at the ciimac- disorder appears to increase with advancing 

age. Not unfrequently it occurs at the climac- 
teric. A considerable proportion of women suffer more or less 
from it about the time the menses cease. 

This itching of the genitals is also one of the contingents of 



158 LECTURES, CLINICAL AND DIDACTIC, 

pregnancy. It is more apt to come on after than before the third 

month, and may either cause abortion, or con- 

Pruritus during preg- tinne to term. Some women always have it 

nancy. ° 

when they are pregnant. Here is a striking 
instance of general and local pruritus in a pregnant woman, pub- 
lished by M. Maslieurat-Lagemard.* 

" Mrs. , aged 32, first became pregnant when twenty-one 

years old. Prior to the sixth month she suffered but little from 

the disorders incident to gestation ; but after 

Case. # . ° 

that time, and without any apparent cause, she 
was attacked with intense pruritus, which extended over the 
whole body. The legs, thighs and genitals were first seized, but 
at the eighth month the itching extended even to the palms of 
the hands and the soles of the feet. The rubbing and scratching, 
which she could not resist or avoid, caused premature labor, im- 
mediately following which the irritation ceased. She became 
pregnant again, and, as before, continued well until the sixth 
month. Then the pruritus returned, and continued until the 
seventh month, when she miscarried. This experience was re- 
peated six times in succession ; so that in all she had eight pre- 
mature labors which were due to excessive pruritus.'' 

Diseases about and within the uterine cervix are sometimes 
accompanied by an inveterate pruritus, which may exist for years, 

and defy all ordinary modes of treatment. It 
d 1 s C e as n e plicatedwithuterinema y ue due to simple induration, or ulceration 

of the cervix, endo-metritis, hydatids, polypi, 
or fibroids. A very painful form of it may arise from inoculation 
and irritation caused by contact of matters with cauliflower ex- 
crescence; and some authors believe that pruritus of the vulva is, 
under peculiar circumstances, a suspicious sign of uterine cancer 
in its earliest stages. (?) In other cases, uterine disease is caused 
by an extension of the inflammation, which is attendant upon the 
pruritus, from the vulva to the uterine cavity. 

As in this case, this troublesome affection may torment the 

woman only during the nursing period. Under 
iaiiTion d to the period ° f these circumstances, weaning will generally 

cure it with as much certainty and promptness 
as did the emptying of the womb in the example just quoted. 

* Gazette Meclicale, 15 Mars, 1848, p. 204. 



ON THE DISEASES OF WOMEN. 1-59 

The danger from pruritus of the vulva is that it may persist 
until it has so exhausted the nervous energies as to leave the sys- 
tem an easy prey to organic disease. Inveterate cases are likely 
to be accompanied by digestive disorders of the 

Prognosis. . L J ° . 

most serious nature. Ihe prognosis will there- 
fore vary with the clinical history, the cause, the complications, 
and the duration of the disease, as well as with the temperament, 
time of life, dyscrasia, and the original strength and vigor of the 
patient. 

Treatment. — This is local and general. It would be cruel to 
deny our patient the use of such palliatives as will mitigate her 
sufferings without in the least interfering with the cure of her 
complaint. And, since the local expedients to which you will be 
obliged to resort must vary in different cases, you should possess 
an ample stock of them in the outset. 

First of all is cleanliness, which can be secured by having the 
parts frequently bathed with suds from castile soap. The honey 
and juniper tar soaps answer equally welL 
Pledgets of old, soft linen may be wet either 
with cold or warm water, as the patient prefers, and applied fre- 
quently. Or wheat-bran water may be used in the same way, 
and, in some cases, injected per vaginum. If there is a vesicular 
eruption, with a raw surface, or the burning in the urethra and 
dysuria are very marked, water, or glycerine, or both, may be 
medicated with the tincture of cantharis, and applied to the vulva 
by means of compresses. The urtica urens is appropriate to the 
erythematous form, with a scarlet surface of the mucous mem- 
brane, and where there is complaint of burning and stinging as 
from nettles. 

In case of aphthous ulceration, you should not forget the com- 
mon borax, and the hydrastis, both of which are in excellent re- 
pute as palliatives in this form of pruritus. An emulsion of olive 
oil and lime water is sometimes of excellent service. Or a roll 
of lint clipped in almond oil may be introduced into the vagina. 
Oolombat recommends a lotion composed of a tablespoonful of 
cologne water to a teacupful of warm water. Lisfranc prefers a 
mixture of starch five parts, and camphor one part, to be applied 
once daily to the inflamed surface, the latter having been washed 
before the preparation is used. Scanzoni extols a liniment com- 



160 LECTURES, CLINICAL AND DIDACTIC, 

posed of chloroform two parts and almond oil thirty parts. Hewitt 
prefers them in the proportion of one part of the former to six of 
the latter. In extreme cases, others prescribe a mixture of melted 
lard and chloroform. Or the rhigolene, ether, or chloroform spray 
may be used exceptionally. 

If there is considerable local inflammation, I am in the habit of 

prescribing a poultice of ground slippery elm, or of linseed meal. 

If the case is chronic, and very obstinate, more 

For vulvitis, syphilitic or especially if it is syphilitic, the surface mav be 

otherwise. . J. «/ «/ J. «/ 

painted over with a solution of the nitrate of 
silver, composed of one grain to the ounce of distilled water. In 
other inveterate examples the chromic and hydrocyanic acids are 
permissible and useful. 

If the itching is due to the presence of pediculi, a mixture con- 
sisting of the ointment of the yellow nitrate of mercury one part, 

and lard three parts, may be smeared over the 

For pediculi. ascarides, etc. _ . 

pudenda. Or an mlusion ot tobacco may be 
applied locally with a view to disgust and destroy the parasite. 
In trichiasis of the vulva you may follow the treatment prescribed 
by Dr. Meigs, as quoted above. If the irritation is due to the 
presence of ascarides in the rectum or vagina, or both, injections 
of common salt and water, olive oil, or of a decoction of garlic, 
may be ordered. 

It is very important to enjoin quiet. The fresh air is, however, 
requisite. Sexual intercourse should generally, 

Rest, diet, etc. . • i -, -i r> i • n l a 

but not invariably, be forbidden. A proper, 
unstimulating diet should be chosen, and every form of alcoholic 
drink denied. 

I will not detain you with detailed indications for remedies that 
may require to be given internally. Let it suffice that the utmost. 

importance must attach to the special cause and 

Internal remedies. .,..-, . 

history of each individual case in which you 
are consulted. For there is no single specific for this affection, 
any more than there is for hysteria. Natrum muriaticum, sepia, 
silicea, sulphur, arsenicum, calcarea carb., conium, mercurius, and 
the various acids, are most frequently given. 



ON THE DISEASES OF WOMEN. 161 



LECTURE IX. 



OVARIAN NEURALGIA. 



Gentlemen : 

An eminent author has insisted that the ovarian stroma is the 
sexual center of the female organization. Whether or not this 
theory is true, it is certain that this spongy structure is erectile, 
and therefore subject to extreme vicissitudes in respect of its cir- 
culation and innervation. For the ovaries are well furnished with 
blood vessels and nerves. This is a necessary condition of their 
functional activity which, as in the case of other delicate organs, 
implies the possibilities of diseased states that shall arise from a 
derangement in their nutritive and nervous supply. 

In health the ovaries are not sensitive. Enclosed in their fibrous 
capsule (tunica albuginea,) they float out of harm's way. But, 
under some peculiar or periodical excitement of 
ovarran li ?rri P ta e tSn Ponentsof tne generative system, as, for example, in coitus, 
menstruation, pregnancy, or parturition, they 
are liable to become irritated, congested, inflamed, or the seat of 
severe neuralgic pain. And since " women are always about to 
menstruate, or menstruating, or ceasing to menstruate ; or the 
womb is gravid or going to become so, or it is recovering from 
the parturient state ; these organs have never an even, steady 
tenor of life." Hence the frequency of ovarian diseases, one of 
the most interesting and troublesome of which is the theme of my 
lecture this morning. 

Etiology. — ■ The neuralgic diathesis is the most powerful predis- 

ponent of ovarialgia. Women who are subject to neuralgia of the 

face, head, teeth, and other parts, sometimes 

The neuralgic diathesis. . x 

suiter severely from this affection. In such 

persons, if anything is wrong in the pelvic region, the pain is very 

liable to become neuralgic, in which case the rectum, the uterus, 

the neck of the bladder, or either of the ovaries, may be the seat 

ii 



162 LECTUBES, CLINICAL AND DIDACTIC, 

of suffering. In this class of subjects the nervous system may have 
been originally weak and subject to painful disorders, or that con- 
dition has, perhaps, been acquired by habits of life, and the sur- 
roundings to which the patient has been subjected. We find 
examples of this kind among seamstresses, who lead lives of toil 
and anxiety, and who subsist upon tea, with insufficient and 
improper food, as well as among those who are buffeted by 
emotional excitement at the expense of their happiness and 
general good health. Such persons are almost invariably ansernic 
or chlorotic. 

This neuralgic predisposition may be complicated with a rheu- 
matic diathesis. I have treated several patients for neuralgia of 
the pelvic organs in whom the suffering was 

The rheumatic diathesis. s. 

directly chargeable to a metastasis or the disease 
from some other part of the body. My own observation leads me 
to conclude that the daughters of* rheumatic fathers, especially if 
the parent was of intemperate habits, are particularly liable to this 
complication. The rheumatic element may be masked, but it cer- 
tainly modifies the nature of the attack, and should not be over- 
looked in its treatment. 

So also of hysteria. Very few hysterical women are exempt 

from neuralgia. Indeed, it is one of the many peculiarities of 

hysteria, that the slightest causes implicate the 

The hysterical diathesis. . ait 

nerve filaments and involve suffering. A local 
congestion which is temporary, incidental, and self-limited, and 
which in other persons would be an insignificant affair, in women 
of this temperament will sometimes give rise to extreme suffering 
of a neuralgic character. It is true that such patients are prone 
to exaggerate their sufferings, but still the fact remains, that in 
hysterical women the peripheral nerve filaments are peculiarly 
sensitive to causes which induce pain. 

The excitement of the generative system to which this class of 
persons is especially subject, is a fertile source of ovarian neural- 
gia. Excessive or fraudulent intercourse ; un- 

Sexual excitement. m 

gratified sexual desire ; menstrual derange- 
ments ; emotional influences, as, for example, too much of thea- 
tre-going, of novel-reading, of dancing, or of the worry and wear 
of fashionable society ; carrying too much or too little weight in 
life, and exemption from proper household cares ; may cause such 



ON THE DISEASES OF WOMEN. 163 

a determination of blood to the pelvic organs, and especially to 
the ovaries, as shall induce this form of neuralgia. 

The same is true of uterine displacements, organic disease of 
the ovaries and of the womb, of pregnancy, and of the parturient 

act. Or it may be caused by nervous shock, by 
and o g v a a n ries disease of uterus contusions or falls, the taking of long rides or 

walks, lifting, jumping, singing, running the 
sewing machine, or, what is worse than any other form of exercise 
for a woman with intra-pelvic disease of almost any kind, the 
dressing of her own hair. 

Clinical History. — The attack comes on abruptly, and without 

premonition or apparent cause. Perhaps she is 

Mode of attack. r . f\ . . , 

seized while walking, or upon turning in the 

bed, upon stepping into her carriage, while sneezing or laughing, 

or, it may be, after the sexual act. 

The pain is acute, paroxysmal, and, contrary to the general rule 

in neuralgia, is increased by the touch and by pressure, whether 

it is slightly or more firmly applied. Ac cord- 
Kind and degree of pain. . & J / ,** 

mg to Churchill, the pam is generally much 

greater than that resulting from ovaritis. It rarely seizes both 
ovaries at once, but frequently alternates. It is described as sud- 
den, intense, excruciating, stabbing, cramp-like, and is apt to be 
accompanied by bending of the body toward the affected side, by 
fainting, falling, vomiting, hysterical spasms, delirium, or diuresis. 
Sometimes it radiates, and, in chronic cases (as also in those which 
occur in pregnancy), it may extend along the corresponding thigh. 
Usually, however, it is circumscribed and limited to the site of the 
ovary, which, as you know, varies in different women and at dif- 
ferent periods. 

It is not uncommon for the patient to describe the pain as ac- 
companied by a sensation as if something would burst in that 
locality. At other times she recognizes a sense 

Peculiar sensations. « . « ' . r» 

of compression, 01 stricture, or 01 strangula- 
tion. Something upon which she puts the tips of her fingers feels 
as if tied up tightly. In some cases she cannot lie down, in others 
to stand is impossible. The pain remits, but does not, as a rule, 
pass away suddenly. The paroxj^sm is very liable to recur. 

When it occurs as a contingent of dysmenorrhcea, the pain is 
" sickening " in character, and peculiarly distressing and exhaust- 



164 LECTURES, CLINICAL AND DIDACTIC, 

ive. In this class of cases, Rigby says, the pain is chiefly confined 

to a spot abont an inch above the middle of 

when incident to men- Poupart's ligament, frequently extending to the 

back, and sometimes down the thigh. Ovarian 

neuralgia is more likely to set in at the very beginning of the 

period, than after the flow has commenced. It may recur in case 

the menses come on scantily for a few hours, or a day, and then 

stop for a little, and finally return more freely. This intermittent 

form of menstruation is very apt to be accompanied by more or 

less neuralgia of one or both ovaries, upon the existence of which, 

indeed, it may be dependent. For the neuralgia may cause the 

menstrual irregularity, and vice versa. 

An engorged state of the ovary is undoubtedly the source of 
suffering in this disease. From the afflux of blood to it, the substance 
of the organ becomes swollen. Its fibrous en- 
velope being firm and resistant, limits the 
expansion of the erectile tissue which it contains, binds it down, 
compresses it, strangulates it, and intense pain is the direct and 
inevitable result. Whatever means are capable of relieving the 
congestion will put an end to the paroxysm. 

So likewise the existence of old, inflammatory adhesions be- 
tween the ovaries and other pelvic viscera, may cause this spas- 
modic or congestive neuralgia, through a perma- 

Peritoneal adhesions. 

nent displacement of the organ. Such an at- 
tachment may be unnoticed and harmless until the period of preg- 
nancy has arrived, in which it is necessary that the ovary should 
ascend beside the womb above the superior strait. " If the peri- 
toneal adhesions be slight, they may perhaps get ruptured as the 
uterus enlarges ; the patient will suffer from severe hypogastric 
pains, especially during the second and third months, and there is 
sure to be very troublesome sickness.'"* But if these adhesions, 
which are sometimes strengthened by fibrous bands and exuda- 
tions, that have cemented the ovary very firmly, are not broken, 
the suffering may either persist to term or it may result in abor- 
tion. 

Diagnosis. — You can diagnosticate ovarialgia from ovaritis by 
the absence of a chill, fever, or other constitutional symptoms at 

* Tanner, on the Signs and Diseases of Pregnancy. Phila., 1868 ; p. 239. 



ON THE DISEASES OF WOMEN. 165 

the outset ; by the suddenness of the attack ; the intensity of the 
pain, which is limited to a small extent of sur- 

From ovaritis. 

face ; by the acuteness and brevity of the par- 
oxysm ; the absence of burning pain in the affected part ; by the 
fact that it occurs most frequently in nervous, hysterical persons ; 
by the self-limited nature of the disease ; and its different modes 
of termination. 

The location of the tumor (in case the ovary is very much 
swollen), the kind of pain complained of, the lack of impulse in 

the tumor when the patient coughs, its occur - 

From hernia. . . ,.,.,. , 

rence in one oi a neuralgic diathesis, and the 
impracticability of taxis, would differentiate the worst case of 
ovarialgia from all forms of enterocele. . 

In neuralgia of the womb the pain extends over a larger sur- 
face, is more marked in the hypogastric than in the iliac regions, 

never alternates between the two sides of the 

From uterine neuralgia. . . ni . . 

pelvis or abdomen, is less sudden in the begin- 
ning, and less excruciating in degree, seldom follows the course 
of the sciatic nerves, and is not so apt to leave abruptly as in 
ovarialgia. 

Prognosis. — This is generally favorable. No one ever dies 
directly of ovarian neuralgia, any more than from its more ordi- 

dinary forms. It may, however, through its 

Indirect results. . " . 1 .. .. . 

persistence and severity, induce such diseases 
of the ovaries, or of the uterus, or of both, as will ultimately give 
rise to very serious consequences. Or, in a reflex way, it may 
light up and perpetuate such sympathetic disorders of the heart, 
of the lungs or even of the brain, as eventually will terminate dis- 
astrously. 

It is not always safe to promise a radical cure. Rheumatic and 
hysterical complications are tedious and intractable. The same 

is true of the contingent irregularities of men- 

Qualify your prognosis. . , . - . 

struation. In most cases, in brief, it is so dim- 
cult to control the patient's habits and surroundings, as well as the 
emotional and sexual influences to which she is subjected, that we 
can only hope to afford temporary relief. 

When it occurs during pregnancy, this painful affection is self- 
limited, generally disappearing after labor. If, however, the 
adhesions have prevented the ascent and development of the 



166 LECTURES, CLINICAL AND DIDACTIC, 

gravid uterus, there is danger of abortion, in which case the risks 
of premature delivery are added to those of the neuralgia. 

Treatment. — The preventive treatment of this disease is very 
important. It consists in removing all causes of undue sexual 
irritation and perturbation ; in regulating the 
kind and degree of exercise to be taken ; in 
changing, if need be, the whole mode of life and habits of the 
patient, and in curing the diseased conditions upon which this 
painful affection may depend. Among the items which come 
under the latter head, none is more prominent and practical than 
to order such a diet and such general hygienic relations as will 
improve the quality of the blood. In neuralgia, nutrition is very 
apt to be impaired. There exists anaemia, or the woman is chlo- 
rotic, and while this state of things continues, a cure is impossible. 
If we would restore those who are ill to their wonted health, it is 
our first duty to supply the conditions upon which health 
depends. 

Milk is the best standard for blood, and should be used, in one 
form or another, by this class of patients. The whites of eggs, 
lean meats, game, salt water food, and vege- 
tables, afford a list from which to select what is 
palatable and nutritious. The diet should be varied from time to 
time. If the appetite has failed it may be stimulated by the tem- 
porary use of pepsin, as sold in the shops, by the extract of malt, 
or by the taking of malt liquors in small quantities. 

If the disease is complicated with rheumatism, great care should 
be taken to protect against vicissitudes of weather, and especially 
against taking cold. As a precautionary meas- 
P ika[ionl rheumatic com " ure °f tn i s kind, I have sometimes directed my 
patients to wear two or three layers of flannel 
over the abdominal and hypogastric regions, in the form of an 
apron applied directly to the integument. A batch of uncarded 
cotton may be sewed into the clothing and worn in a similar 
manner. The feet should always be kept dry and warm, but more 
especially "at the month." Because of the erratic nature of the 
disease, and its liability to metastasis to the ovary, you should 
remember that revulsive applications to the seat of rheumatic in- 
flammation, when it is located in other parts of the body, are par- 
ticularly hazardous in the case of women who are subject to sexual 



ON THE DISEASES OF WOMEN. 167 

derangements. The same is true of the use of the ointments 
which are sometimes prescribed for cutaneous eruptions. 

During the paroxysm we must institute measures to relieve the 

suffering as speedily and safely as possible. In every variety of 

acute painful disorder which is located in the 

Palliatives. . 1 . .. . 

uterine or the ovarian regions, warm applica- 
tions are more grateful and soothing than such as are either cool 

or cold. This is especially true in case of intra- 
thaI a c^d ai3pHcations be " er P eiy i c neuralgia, upon which the warmth seems 

to act as a species of anodyne. Aran's expe- 
dient of introducing the speculum, and filling it with powdered 
ice for the relief of ovarialgia, is too harsh, and might be indi- 
rectly injurious. 

Acting upon the clinical hint that warmth is better than cold, 
we may order the application of flannels or towels that have been 

dipped in hot water, or of dry heat in some 

Topical expedients. •-ii-if t i t ni 

available torm, directly to the seat 01 the pam. 
If the suffering is of traumatic origin, one part of the tincture of 
arnica may be added to ten of hot water and applied locally. If 
it is rheumatic, the extract or the tincture of hamamelis, or of 
aconite, may be used in the same manner. Or the same sub- 
stances mixed with warm water and glycerine, may be thrown 
into the rectum or into the vagina. If the attack is incident to 
dysmenorrhcea, the warm sitz-bath may be serviceable. 

Sometimes the pain will be made to vanish by the topical appli- 
cation of the strong tincture of the aconite root. Or a very little 
veratrin dissolved in glycerine, or mixed with simple cerate, may 
be rubbed in gently. A mixture, consisting of chloroform one 
drachm, and olive oil and glycerine each one ounce, may be ap- 
plied to the integument covering the tender ovary, or, better still, 
introduced into the vagina, by means of a cotton tampon which is 
saturated with it. A thread should be attached to the tampon to 
facilitate its removal. It may be allowed to remain for some 
hours. An injection of the same substances may be thrown into 
the rectum. You should remember, however, that, owing to con- 
tiguity of structure, injections thrown into the rectum for the 
relief of ovarian pain, are much more useful and prompt in their 
action in affections of the left than of the right ovary. 

In exceptional cases the suffering depends on the presence of 



1(38 LECTURES, CLINICAL AND DIDACTIC, 

dry, hard, fecal matters lodged in the rectum, and to unload the 

bowel affords immediate relief. In very severe 

Remove fccai accumu- ca ses of ovarialgia, if the means were at hand, 

lations. . 

the ether spray might be applied to the iliac 
region with excellent effect. Unless complicated with hysterical 
spasms, general anaesthesia is not necessary. 

I know that these and kindred expedients are prohibited by 
some physicians, who insist that they are both unnecessary and 
harmful. But it is my duty as a teacher to acquaint you with 
resources that may be useful in emergencies, and which are some- 
times permissible on the score of humanity. It is for yourselves, 
and not for others, to say whether and how often you will employ 
them. 

Of the various internal remedies for ovarialgia, perhaps the 
valerianate of zinc is most frequently prescribed. It seems espe- 
cially adapted to the relief of the different 

Valerianate of zinc. _ 

forms 01 neuralgia which are engrafted upon 
the hysterical constitution. For it obviously has some specific 
curative relation to the ovaries themselves, and through them, to 
the whole nervous organization of woman. It will sometimes put 
an end to the paroxysm at once, but its best effect is in prevent- 
ing a return of it. It may be given in the third decimal tritura- 
tion, and repeated from two to four times daily. If the patient 
has ovarian neuralgia before menstruation, she may anticipate its 
return and avert the suffering by taking a few doses of this 
remedy a day or two in advance of the period. 

Atropine is useful under the same indications for which bella- 
donna is generally given. In very severe attacks it may serve to 
stop the pain, quiet the nervous perturbation^ 
and promote rest and sleep. The cases to which 
it is most appropriate are those in which there is a strong ten- 
dency to ovarian congestion, with intolerance of light and noise, 
dilatation of the pupils, and delirium ; also, when the ovarialgia 
is accompanied, as it sometimes is, by vaginismus. When the 
menstrual return is characterized by downward pressure of the 
uterus, as if it would be forced out at the vulva, and in conse- 
quence the patient is obliged to lie in bed for some days ; and 
when there are incidental paroxysms of acute pain in either 
ovary ; this remedy is almost specific. Two grains of the third 



ON THE DISEASES OF WOMEN. 169 

trituration may be dissolved in half a glass of water and a tea- 
spoonful of the solution given every one to three or more hours. 
Or it may be given in small powders dry upon the tongue. In 
some cases, however, there is such a susceptibility to the action of 
atropine, that you will be obliged to substitute it with belladonna 
in a medium or higher potency. 

Colocynth is applicable to neuralgia in the inguinal region, with 
boring, tensive, or stitching pains in the ovary, in case the symp- 
toms resemble those of hernia, contractive pain 

Colocynth. . 

in the stomach, with eructations, nausea, pallor, 
coolness of the extremities and cold sweat. Also if there is inci- 
dental colic, with disposition of the patient to bend herself double. 

Other remedies which may be useful are cantharis, coffea, 
chamomilla, cocculus, cuprum met., ignatia, platina, pulsatilla and 
sepia. For their special indications I must refer you to the 
materia medica. 

Dr. W. H. Holcombe reports* that, while giving naja to a very 

intelligent patient, a physician's wife, for organic disease of the 

heart, " she complained that it contained a 

Naja. 

symptom altogether new to her — a violent, 
crampy pain in the region of the left ovary." " I met," he says, 
" a similar case a week afterwards, and gave naja, 3d. It was 
relieved immediately. I have verified its value several times. 
Not a month ago I had one of those severe cases of ovarian con- 
gestive neuralgia — for that is the best name I can give it. It had 
resisted chamomilla and hyoscyamus, both at the 6th ; generally 
my first prescription. I was about to prescribe caprum metalli- 
cum, 6th, (which is excellent in those cases), when the patient 
related the curious fact that she had violent palpitation of the 
heart whenever the ovarian pain came on. I gave naja, 3d, and 
both symptoms disappeared as if by magic." 

My friend, Dr. R. N. Foster, of this city, has eonficfeiice 

in the third decimal trituration of ammonium 

Ammonium muriaticam. 

muriatic um. 

Those members of the class who attended the last meeting of 

the Chicago Academy of Medicine will recall 

Dr. Ballard's report of a very interesting ease 

of this disease in a pregnant woman. The affection occurred in 

* United States Medical and Surgical Journal, Vol. I, p. 234. 



Ignatia. 



170 LECTURES, CLINICAL AND DIDACTIC, 

her first pregnancy, and was uncontrollable by the old fashioned 
means. She went through to term, however, without serious 
accident. In the second pregnancy the same symptoms came 
back again, and she suffered extremely. The paroxysms of pain, 
sometimes in one ovarian region and again in the other, came on 
almost daily. She was extremely nervous, with headache, and 
the slightest noise startled her. The doctor prescribed three 
powders of ignatia, 200th, one to be taken every night. The 
paroxysms immediately became less severe in degree, and less 
frequent, some weeks elapsing between them, and she got through 
safely, with much less suffering than before. 

If I may judge from my own observation, the cimicifuga is a 
good remedy for ovarian neuralgia occurring in rheumatic subjects. 
It seems also adapted to women of dark hair, 
eyes and complexion, and to those who are the 
children of intemperate parents. In this latter class of subjects it 
is suited to the relief of contingent attacks of hysteria, dysmenor- 
rhea, intense reflex pains, as, for example, angina pectoris, or the 
characteristic infra-mammary pain in the left side of the chest. 

EXCORIATED NIPPLES. 

Case. — Mrs. G.'s third child is but four weeks old. This babe 
is a fat, hearty boy, while the mother is slender, but of general 
good health. She reports having passed through her lying-in 
without any serious illness. She has, however, suffered extremely 
from sore or excoriated nipples. This trouble began immediately 
after the appearance of the milk, on the third day after delivery, 
and has continued until the present time. She says that she 
could " get on very well, but that each time after nursing the 
nipple is left raw and bleeding ;" and that " when the little fellow 
lets go his hold, it almost takes her life." She had a similar 
experience with each of her former children, from which, despite 
all the means employed, she did not recover until they were 
weaned, at the age of three months. 

This is by no means a trivial case. In private practice you 
may encounter forty of them for every one like that upon which 
my brave colleague, the professor of surgery, has just performed 
a capital operation. And, unless you know how to treat them, 
each one may give you forty times as much trouble. Although 
the nipple may be accidentally torn off by the child, you will not 



ON THE DISEASES OF WOMEN. 171 

be permitted to dispose of this troublesome member by ampu- 
tation. 

Sore nipples are more frequent in primiparas than in multiparas. 

There are those, however, who, like our patient, suffer from them 

with each successive pregnancy. The affection 

Most frequent in primi- sometimes begins during the later months of 

gestation, but usually not until the child has 

been " put to the breast" a few times. If the skin covering the 

nipple is very tender, thin and delicate, the first 

Local and general causes. . . . . . 

attempts at nursing may increase its sensitive- 
ness or strip off the epidermis in some places. The more vigorous 
and voracious the child the greater the danger in this respect. In 
women with light complexions, and light or red hair, the cuticle 
is very delicately organized, and easily removed. There is a 
popular idea that, because they are stronger and more rough in 
their little manners, boys are more apt than girls to wound the 
nipple while nursing. There is little doubt but that this painful 
affection is sometimes due to the removal of the sebaceous matter 
from about the nipple by the mouth of the infant. In other cases 
the nipple is bruised by the gums. Or it may arise from a lack 
of cleanliness, or from not drjdngthe nipple so carefully as should 
be done after nursiug. Sometimes it may spring from a depraved 
or cachectic condition of the general system, chargeable to 
original organization or to the drainage which is consequent upon 
gestation. Again, it may be caused by an aphthous condition of 
the child's mouth, whereby it has been inoculated with a poison- 
ous principle. In exceptional cases the child may be syphilitic, 
and the erosion of the nipple will be found to present some 
specific peculiarities. 

The first symptom complained of is a burning or scalding of 
the nipple when the child takes hold of it, or upon its removal 
from the breast. This sensation may be accom- 
panied or followed by pain which is more or 
less acute. Sometimes the nipple, and again the whole breast, 
feels as if bruised. Or they may be the seat of acute, lancinating 
or stinging pains. In some instances the mother can scarcely 
persuade herself that her nipple has not really been torn off by 
the child. The torture of nursing: the infant is sometimes very 
great. A fissure or chap in the skin, which is scarcely visible to 



172 LECTUBES, CLINICAL AND DIDACTIC, 

the naked eye, may be sufficient to cause the most extreme and 
exquisite suffering. Women of the utmost courage and fortitude 
are not unfrequently brought to tears by this experience. Occa- 
sionally the weak and irresolute, more especially those who desire 
an excuse for weaning the child, refuse to nurse it after a few 
trials. 

Upon careful examination we may, perhaps, find that a consid- 
erable portion of the nipple has really been denuded of its invest- 
ing cuticle. This excoriation is generally most 
marked at the free extremity and apex of the 
organ. It may arise from the warmth and moisture of the child's 
mouth, which seem as it were, to blister it and to separate the 
scarf skin from the delicate derm beneath. These abrasions may 
be either superficial or otherwise, according to the length of time 
that has passed since they commenced, and the lack of cleanliness 
or of proper treatment. They sometimes develop into broad 
ulcers, which are exceedingly vascular and irritable. They are 
slow to heal, because the reparative material thrown out is apt to 
be washed away or removed by the child before it is fully 
organized. 

Not unfrequently the fissures will be found to consist of long, 

narrow, linear ulcers, which are deep-seated and intractable, and. 

which bleed easily. These ulcers may dip down 

The ulceration. . . _. _ " 

into the nipple perpendicularly from its summit, 
or they may take a transverse direction, and finally cut off one- 
third, one-half, or the whole of the organ. They are exceedingly 
painful, particularly when exposed to the air, and in case the lips 
of the fissure, or hair-like ulcer, separate from each other. They 
may even become fistulous. The symptoms are aggravated by 
each attempt at nursing. The discharge from the abraded surface, 
or from the fissure, soon dries upon the nipple and forms a scab, 
beneath which pus is sometimes collected in considerable quantit}\ 
The injury done to the nipple by the nursing process may cause it 
to bleed so freely as to sicken the child and induce vomiting. 

In exceptional cases this affection may begin with an herpetic 
eruption about the nipple. The little vesicles are broken, 
and the almost constant irritation of nursing causes them to 
develop into ulcers, which finally coalesce and give rise to symp- 
toms such as I have alreadv detailed. At other times it is the 



on" th:e diseases of women. 173 

outgrowth of a species of scorbutic cachexia, and accompanies 
the nursing sore mouth. 

Perhaps the most serious consequence of excoriated nipples is 

the danger of mammary abscess, which may result in any case 

from a lack of determination, or from neglect 

so?en? P pie r s y aWss from on tne P art of tne P ati ent and nurse, to have the 

breasts well and frequently drawn. The milk 
accumulates, the gland becomes painful, indurated and inflamed 
from over-distention of its ducts. The suppurative process is 
soon established, and constitutional and local symptoms of a grave 
character follow. It is in this manner that the worst examples of 
mammitis and mammary abscess may be indirectly referable to an 
erosion or ulceration of the nipple. If the patient is addicted to 
the wearing of tight dresses, this unfortunate result is all the 
more likely to follow. 

Treatment. — As prevention is better than cure, so we may save 
trouble by the use of expedients which are designed to prevent 

the possibility of the nipples becoming sore. 

They may be " hardened " by applications of a 
weak lotion of the tincture of arnica, of alcohol and water, of 
brandy and water, of a linen cloth constantly wet with rum, by a 
wash consisting of equal parts of the tincture of myrrh and rose 
water, by bathing them in port wine, in green tea, or in a mixture 
of three parts of green tea with one of brandy. Or you may 
direct the use of a cerate of white wax and butter in equal pro- 
portions. In the case of primiparaB, simple prophylactics of this 
kind are especially serviceable in the later months of pregnancy. 
Care should be taken that the clothing over the breasts is not too 
warm and tightly fitting. It should be light and thin, especially 
during the last month of gestation. These precautionary meas- 
ures are also suited to those who have suffered from sore nipples 
on previous occasions, and in whom, if possible, it is most desira- 
ble to avert such a calamity in the future. 

Here, as everywhere else in the practice of your profession, you 
will find great need of discrimination. For although these and 

other expedients are useful and harmless, when 

Need of discrimination. .,.«.« 

properly applied, they may work mischief it 
wrongly used. And while too much blame is frequently laid at 
the door of monthly nurses, it is still true that they do a groat 



174 LECTURES, CLINICAL AND DIDACTIC, 

deal of harm by resorting to traditional specifics of whose real 

properties and powers they are ignorant. An eminent author 

says : " Most nurses, indeed, possess a cata- 

Watch the nurse. n , c -t r 

logue oi nostrums — never-tailing cures — tor 
chapped or ulcerated nipples ; and I think many of the most dis- 
tressing cases of the kind we meet with are occasioned by these 
busy characters taking the management on themselves , and, as is 
usual with the ignorant, relying implicitly on the virtue of their 
favored specific alone, without attending to the necessity either of 
protecting the nipple, or of duly evacuating the breast." 

If there is simple abrasion of the nipple, it may suffice to have 
it carefully cleansed and then dried with a tuft of soft linen or 

charpie, as soon as the child is taken from the 

breast. Then apply a cold mucilage of slippery 
elm, or, if there is much heat and burning, small cloths wet in cold 
water. Or the nipple may be dusted with some finely-powdered 
arrow-root, starch, gum arabic, borax, or white sugar. Or the oil 
of sweet almonds, arnica oil, simple cerate, or the spermaceti oint- 
ment, may cure the case by the exclusion of air and moisture. 
If there is aphthous ulceration, borax, hyclrastis, baptisia, or 

one of the mineral acids diluted with cool or 

For aphthous ulceration. 1 1 

cold water, may be applied topically. In some 
cases simple rose water answers equally well. 

The nitric, phosphoric, and muriatic acids are also curative in 
case of fissures, chaps and linear ulcers of the nipple. The organ 

should be cleansed and dried after nursing, and 

For the linear ulcers. . 

a weak solution ol one ol these acids m water 
and gh^cerine applied with a camel's hair pencil. Some physi- 
cians place great confidence in a lotion composed of an alcoholic 
solution of gum benzoin and glycerine in equal parts. A domestic 
expedient of real utility in some cases consists in the application 
of the oil which may be expressed from the yolk of a hard-boiled 
egg. Or a species of flexible varnish may be extemporized by 
rubbing four parts by weight of the yolk of an egg with five parts 
of glycerine in a mortar, and applying it over the whole nipple. 

Dr. Simpson recommended the topical use of collodion ; but this 
is painful, and seldom answers very well. The mixture of collo- 
dion and castor oil extolled by M. Latour might be less severe and 
more efficacious. Some practitioners prefer the arnicated collo- 



ON THE DISEASES OF WOMEN. 175 

dion. Others the cerates of graphites, or calendula. A popular 
and efficacious remedy in some cases is the mutton marrow. In 
obstinate, chronic cases, the nitrate of silver in stick or solution 
carefully applied will stimulate granulation and close the ulcer. 
Or you may bring the edges of this linear ulcer together and 
secure them in contact by bits of adhesive plaster properly 
adjusted. For this purpose the flexible plaster which is spread 
upon silk is preferable to the old variety. 

If the child nurses directly from the nipple, or, in other words, 

if a shield is not used, the nipple should always be cleansed after 

either of the above named applications, before 

cleanse the nipple before ft £ s a aain put to the breast. The chief obiec- 

nursing again. o j. j 

tion to cerates and ointments is the difficulty 
of removing them under these circumstances. 

You will find upon the table a dozen kinds of nipple shield. I 
can not recommend any of them as suited to every case. My plan 

is to try one and another, if necessary, until I 

Choice of nipple shield. ,, , . ,_,, 

nnd the one that my patient can use. I he more 
simple the instrument the better. If it has too long a teat it will 
be very apt to occasion soreness and inflammation in the roof of 
the child's mouth. It should be kept sweet and clean. In case 
the breast is so exceedingly sensitive that the mother cannot bear 
it touched, the shield which is arranged with a flexible tube 
between the child's mouth and the nipple of the mother answers 
best. If the milk does not flow very readily 
through the shield, it may first be drawn a few 
times by an older child, or very carefully by the nurse. If the 
child refuses to take hold, a little tact and starvation will mend 
his manners. The shield should be used on both breasts, and not 
upon one exclusively, else while one gland is well drawn the other 
may not be half emptied, and mammary abscess may follow. If 
the skin of the nipple is very delicate, the shield should be used 
from the first, and the babe not allowed to take hold of the nipple 
at all. 

The advantages of this little instrument are that while it 
secures, if appropriately and carefully used, a thorough evacua- 
tion of the breast — preventing the inflamma- 

Benefks of the shield. . . , . , . 

tion and suppuration which m many cases would 
be inevitable without it — it also averts and alleviates suffering. 



176 LECTURES, CLINICAL AND DIDACTIC, 

By preventing the removal of reparative material which is thrown 
out, as well as by allowing lotions and ointments time to act, and 
by keeping the nipple from direct contact with the child's mouth, 
protecting it from the injurious results of suction and friction, it 
hastens the cure. The child should be nursed regularly, as often 
as once in three hours during the day. 

If there is a high degree of local inflammation, soothing appli- 
cations of cold water or rose water, or, better still, a cold emol- 
lient of slipper}^ elm, may be applied. In some 

For local inflammation. ... ., , . , 

cases it is impossible to cure an excoriated or 
ulcerated nipple while the inflammation in the loose cellular tissue 
within and about the base of the organ continues. Weaning is a 
final expedient. 

Among the internal remedies calcarea carbonica, sepia, sulphur, 
graphites, rhus tox., chamomilla, silicea, mercurius, alumina, hepar 

sulphuris, nux vomica and causticum are the 

Internal remedies. . . 

more prominent. In selecting the appropriate 
remedy particular prominence should be given to the patient's 
antecedents, the peculiar condition of her health during preg- 
nancy, and to acquired predispositions, as well as to the distinctive 
symptoms of which she complains. 



OX THE DISEASES OF WOMEN. 177 



LECTURE X. 

urethritis. 

Gentlemen : 

Here is an example of a disease with which you should be 
familiar : 

Case. — Mrs. ■ — — , aged 28, has been ill for fourteen weeks. 
She is the mother of two children, the youngest of which is one 
year old. The babe was weaned at six months, since which time 
she has menstruated regularly. On the eve of the regular " period " 
she was seized with a strong desire to urinate, but, being " down 
town on a shopping expedition," she could not conveniently re- 
spond. Although suffering great pain in consequence, micturition 
was deferred for more than an hour, during which interval she 
rode home, a long distance, in the street-car. But the simple 
evacuation of the bladder did not end her sufferings. For she 
still felt an almost irresistible call to urination, which has tor- 
mented her at intervals of from ten minutes to an hour ever since. 

The flow has never been involuntary. If she lies quietly upon 
her back, the irritation subsides, but the moment she turns upon 
either side the dysuria comes on again. Although in a less marked 
degree, standing and sitting produce the same result. She cannot 
sit in a chair five minutes without the most disagreeable sensations 
and throbbing, which are referred to the meatus and the course of 
the urethra. She says the pain is most acute and burning during 
the flow. This pain is described as always of a burning character. 
The urine is sometimes cloudy, with a ropy sediment, but usually 
quite natural in appearance. It has never been bloody or highly 
discolored. The quantity voided in twenty-four hours is neither 
excessive nor deficient. 

Two years ago she had a similar attack, which continued for 
three weeks and appeared to subside of itself. Although her at- 
tention had not been called to the fact before, she now remembers 
that it followed a similar imprudence. She is quite positive that 
it bore no relation to the birth of her first child. This patient has 
already been under the care of several physicians, at whose pre- 
scription she has taken buchu, copaiba, oil of turpentine, and the 
usual drugs, including the extract of belladonna in laro'e doses. 



178 LECTURES, CLINICAL AND DIDACTIC, 

She has also made use of sitz-baths, suppositories, herb teas, etc., 
etc., but with only the most temporary relief. 

The uterus is prolapsed the moment she assumes the upright 
position, whether in standing or sitting. With this exception, the 
womb is normal in every respect. The vagina is not inflamed, 
neither is it especially sensitive, except along the course of the 
urethra. Pressure on that canal from above downwards causes 
the same pain of which she complains when passing water. It 
also forces the escape of a muco-purulent fluid from the meatus 
urinarius. The orifice of the urethra is more highly colored and 
tumefied than the surrounding mucous membrane. 

It is a singular fact that most writers upon the diseases of 
women have said little or nothing of this painful affection. We 
cannot attribute this oversight to its infrequency, for, in the female 
subject, urethritis is much more common than stone in the bladder 
or cystitis, both of which diseases have received a due share of 
attention at the hands of the gynaecologist. Nor is it an insignifi- 
cant complaint. For whatever occasions such suffering as our 
patient has experienced, has a claim upon us for relief. 

Urethritis may be acute, sub-acute, or chronic. The two latter 
are the more frequent. It may arise from taking cold, more espec- 
ially during the menstrual period, getting the 
feet and limbs wet, sitting in wet skirts at 
church, or in the concert room ; from the extension of the inflam- 
mation in case of vaginitis along the mucous membrane of the 
urethra, or from the irritation of pruritus in the same canal ; vas- 
cular tumors of the meatus ; polypus of the urethra ; from acrid- 
ity of the urine; the contact of leucorrhoeal discharges, or of 
vitiated semen ; from the pressure of a dislocated womb ; uterine, 
ovarian, hernial, or pelvic tumors ; cancer ; misplaced or illy- 
adjusted pessaries ; horseback riding ; mechanical injury during 
labor, or the induction of abortion by those who are ignorant of 
anatomy ; too forcible or too frequent coitus, especially at the 
month ; also from masturbation, gonorrhoea, syphilitic ulceration, 
urinary calculus, and indirectly from neglect to respond to the 
promptings of nature when the bladder should be emptied. A 
spurious form of this disease is sometimes met with in hysterical 
women. In the sub-acute variety the attack may recur with each 
menstrual period. 

The most prominent symptoms are burning and smarting or 



ON THE DISEASES OF WOMEN. 179 

scalding along the course of the urethra, with frequent desire to 
urinate. In many cases this burning sensation 

Symptoms. . . . 

is continuous, being aggravated by the now of 
urine. In others it commences when the patient is half, or, per- 
haps, wholly through with the act of micturition, and continues 
for some moments after the discharge is completed. The burning 
and the urging to urinate are increased by motion. Hence, if the 
patient persists in walking about, or sitting up, these symptoms 
are aggravated. For this reason, she is generally better at night. 
She may find it possible to lie in a particular position, and in 
that only, with a relative degree of comfort. Thus, while our 

patient is easy upon her back, she cannot turn 

Posture chosen. . . , . , . . 

irom it upon either side without increasing the 
difficulty. Sometimes the erect position is intolerable. It is par- 
ticularly so if the case is complicated with prolapse of the womb, 
or uterine or other intra-pelvic tumors. The vesical tenesmus is 
very apt to be increased by the same cause. 

Usually, the character of the urine is not changed in any par- 
ticular, except that it is mixed with mucus. The blennorrhagic 

discharge may be quite profuse or scanty, ac- 

Character of the urine. ° \ . , . _ , , 

cording to the duration and gravity 01 the attack. 
It varies, also, with the individual constitution, scrofulous persons 
being more apt to have a copious flow of mucus than others. The 
mucus is mixed with the urine when it is voided, but afterwards 
separates and settles as a cloudy, ropy material. It is never 
bloody. In very nervous women, after a paroxysm of strangury, 
there may occasionally be an abundant flow of pale, limpid urine, 
such as frequently follows a hysterical fit. 

When you visit such patients and inquire in general terms con- 
cerning their ailments, you will most likely be told that they have 
disease of the kidneys. For, however intelli- 

A domestic fallacy. 

gent in other matters, most women suppose that 
anything wrong with urination implies that the kidneys, and not 
the bladder or urethra, or both, are at fault. A diligent inquiry 
into the especial symptoms will enable you to discriminate between 
urethritis and nephritis, for example, and you should not, there- 
fore, be satisfied to prescribe upon the patient's diagnosis. 

Cases of this kind might, perhaps, be confounded with stone in 
the bladder. The pain at the close of, and after urination, the 



180 LECTURES, CLINICAL AND DIDACTIC, 

increased suffering and strangury from moving around during the 
day, and the frequent, scant} T , interrupted flow 

Diagnosis — from stone. _ , , „ r . t-» j 

oi urine, are common to both artections. .But 
where the symptoms depend upon urinary calculus, we shall find 
them modified and supplemented by others which are lacking in 
urethritis. The pain caused by the contraction of the bladder 
upon the stone is sometimes acute, but generally of an aching 
character. And although it may extend along the course of the 
urethra, it is not accompanied by the burning sensation of which 

Mrs. complains. In stone, the urine is more or less bloody ; 

its chemical reaction varies with the kind of deposit ; the micro- 
scope detects an excess of some of its earthy constituents, and by 
"sounding" the bladder we recognize the presence of a foreign 
body contained within it. 

Cystitis is accompanied by more or less marked constitutional 
symptoms, as chill, fever, anorexia, and rapid loss of strength. 

The pain, which is referred to the pubic region, 

From cystitis. i 

is m the first stage acute, lancinating, and ex- 
treme in degree when the bladder begins to contract. It is 
increased by motion, by pressure, and is worse at night during the 
febrile exacerbation. It may be of a burning character, but is 
more apt to implicate the rectum than the urethra. There is also 
a feeling of distension of the bladder. In advanced stages the 
abdomen becomes tender and tumefied, and in its further develop- 
ment the affection differs entirely from urethritis. 

It is extremely difficult, and sometimes quite impossible, to 
determine whether a given case of urethritis is or is not compli- 
cated with gonorrhoea. If the inflammation is 

From gonorrhoea. . 

specific, the attack is more likely to be accom- 
panied by marked constitutional symptoms, by more intense suf- 
fering when the urine is passed, by a more copious discharge of 
mucus, and, what is still more characteristic, the more acute symp- 
toms subside spontaneously in from two to four days. But the 
particular history of the case, and especially the habits of the 
patient and of her husband, will help you to settle the question 
as between a benign and a specific inflammation in the urethra. 
Let me recommend, however, that, whenever it is possible, you 
shall give all parties concerned the benefit of a doubt, and pro- 
ceed to the relief of the symptoms which are actually present. 



OX THE DISEASES OF WOMEN. 181 

Treatment. — Perhaps no better opportunity will offer in which 

to say a word concerning the length of time required for this and 

similar diseases to recover under proper treat- 
Rapid cures exceptional. . 

ment. In some of our books and journals you 
will find it reported that a single dose has cured such a patient 
almost instantly. The inference is that if we prescribe carefully 
and accurately, the relief will be certain and speedy. The truth 
it often quite the reverse. Such a case as this, one in which a 
poor woman has been ill with marked and decided local inflamma- 
tion for many weeks, must, in the nature of things, convalesce 
slowly. And so is it with the majority of diseases that the physi- 
cian is required to treat. 

The ill effects of motion are so manifest in urethritis that the 
first condition prescribed should be rest in the recumbent position. 

The patient may be allowed to lie on the back, 
poStion in the recumbent or upon either side, as she prefers, but should 

not be permitted to stand, sit, or walk about. 
Riding would be equally injurious. She should as much as possi- 
ble refrain from doing anything which would increase the pain or 
the frequency of urination. For this reason, it is best to pre- 
scribe sexual abstinence also. 

The diet should consist of plain, wholesome food, which is 
freed from condiments and easily digested. All kinds of wines 

and liquors are poisonous. Tea may be allowed 

The diet and drinks. . \ . r J 

in moderation. Ihe meals should be taken 
regularly. Vegetables are better than meats for these patients. 
If she eats an excess of sugar her sufferings may be greatly 
increased in consequence. Diluent drinks, as rice water, gum 
arabic, an infusion of flaxseed or of slippery elm, may mitigate 
the suffering by rendering the urine less stimulating and acrid. 

If the case is at all obstinate or chronic, a careful examination 
should be made of the meatus urinarius, the urethra, and adjoin- 
ing organs. If there is a vascular tumor at the 

General indications. . . . 

orifice, or a polypus m the canal, remove it by 
the scissors, ligature, or caustic, as you think best. If the uterus 
is displaced, correct the deviation and cure the remaining symp- 
toms with appropriate internal remedies. If the inflammation is 
a sequel of vaginitis, or of pruritus of the vulva, treat it as you 
would have treated the idiopathic affection. And so likewise if it 



182 LECTURES, CLINICAL AND DIDACTIC, 

is incident to leucorrhcea or any form of menstrual derangement. 

In gonorrheal urethritis, especially if there is considerable 

inflammation and heat in the vagina also, I know of no remedy 

so well adapted to the relief of the acute synip- 

For gonorrhoeal urethritis. . «-i-r»«-iii« » 

toms as atropine 3d. .besides this we have 
aconite, cantharis, cannabis sativa, and mercurius, which may be 
given under appropriate indications. 

Simple, uncomplicated cases may require cantharis, cannabis, 
conium, belladonna, nux vomica, calcarea carbonica, hepar sul- 

phuris, or mercurius corrosivus. Mrs. will take a dose of 

cantharis 3d once in three hours. 

MEMBRANOUS DYSMENORRHEA. 

I will now invite your attention to the following remarkable 
case, which is reported by the patient herself: 

Case. — I was born in July, 1834, in C , Ohio. Soon after 

my birth an eruption made its appearance on the skin, resembling 
rash, occasioned, it was then thought, by the extreme heat of the 
season. I passed the usual diseases of children very early in life, 
and, with the exception of this eruption, which appeared almost 
every year during the summer months, and generally upon the 
lower parts of my limbs, I was a vigorous, active child, full of life 
and spirit, and in apparent perfect health. At the age of fourteen 
years and five months the menses made their appearance. The 
first discharge was plentiful, but attended with no pains or incon- 
venience whatever. One year after they were suppressed about 
three months — caused by thin shoes, wet feet, and not early 
acquainting my mother with the fact. I was soon set right with 
" Cooper's pills." I felt well during the suppression. At sixteen, 
while at boarding-school, my appetite grew voracious, and I ate 
immoderately of all kinds of food, pickles, and sweetmeats. The 
rash had somewhat lessened in its appearance each summer as I 
grew older. It was, however, upon my body one day when, just 
after dinner, in passing through a hall to which the outer doors 
were open, I met a furious gust of wind from an approaching 
thunder-storm. At the moment I noticed no uncomfortable sen- 
sation, but was shortly seized with great difficulty of respiration 
and extreme prostration, and in less than an hour my life seemed 
hopeless to those around me. This was the first attack of any- 
thing like illness since my babyhood. Two physicians were 
speedily called, who said, " the rash had suddenly struck inward." 
Two days before this I remember to have been very nervous, so 



ON THE DISEASES OF WOMEN. 183 

that I could not go to sleep on retiring, but did not know that 
anything ailed me. The doctors gave me tumblers full of a mixt- 
ure of asafoetida ; valerian was also given. I do not know what 
else was administered, as I was only partially conscious. My suf- 
fering was almost wholly from the gasping and struggles for 
breath. The rash never made its appearance again until I was 
thirty-four years old. I was left weak and sick (/think, from the 
effect of the dosing). It was one or two days before I could be 
removed home. Very soon my monthly period came on, attended 
with some pain. My mother told the physician, and he gave me 
hyoscyamus. My school days ended with my first illness. I was 
never able to return to school-life again. The remainder of that 
summer I was weak, and very nervous frequently ; had severe 
palpitation of the heart, and often could scarcely control my limbs 
and face from twitching violently, which they sometimes did in 
spite of me. The physicians prescribed for " nervous paroxysms," 
4i constipation," and " general debility." I took quantities of the 
different preparations of iron and nervines. One medicine was to 
be dropped, " eighty drops every two or three hours." I knew 
nothing of modern glass-drop measures, and went entirely through 
the "dropping" ordered each time as prescribed. During the fol- 
lowing eighteen months dyspepsia and nervousness were my prom- 
inent troubles ; also obstinate constipation, occasionally having 
some pain at my menstrual periods, which grew somewhat irregu- 
lar ; but I entered into the usual duties of life, and passed for 
being in pretty good health. 

I was married at eighteen. After marriage, nothing about my 
menstrual periods attracted my attention for three months, when 
I passed over seven weeks without them. My form grew some- 
what fuller, and I craved certain articles of food. I took u Coop- 
er's pills" at 1113^ own instigation. When the discharge made its 
appearance it was attended with great pain, so that I was obliged 
to go to bed. I felt very sick, and a physician was called — one 
whom I had never seen. He gave me soothing medicine, but 
never said what ailed me. He attended me several months, but 
never inquired about anything but my constipated habit, and the 
nervous condition of my system. The following monthly period 
I was able to keep out of bed by taking spirits of camphor, which 
he gave me, very often through the day. During that year I had 
severe nervous paroxysms, violent jerking of the limbs and body, 
especially at night. In a few months I suffered extremely with 
every menstrual period the first twelve or twenty-four hours. 

I then went to C , to the care of the physician who had 

attended at my birth, and had known me all my life. He was the 
first who made vaginal examination. He reported a partial w * retro- 
version of the uterus," and said I had " ovarian tumor." I went 



184 LECTURES, CLINICAL AND DIDACTIC, 

through a long series of blisters on my spine and abdomen, purga- 
tives, etc. I was in his care more than a year. As I could not 
live in the city, I was not constantly with him. I never could 
myself discover the slightest soreness or enlargement in the ova- 
rian region, and wondered that I could find no evidence of the 
tumor. About this time I began suffering with what seemed to 
be rheumatism in my right limb, particularly when on my feet, or 
standing much. I rarely ever had it when warm or in a reclining 
posture. 

In a year or more I grew weary of going into C , of blister- 
ing and doctoring, and did without professional aid for a year or 
two. I did better without it than with it, as my general health 
was better. About this time, I once took chloroform to have a 
tooth extracted. It was with great difficulty that I was revived 
from its effects, and for sixteen hours I kept constantly sinking 
away. 

I next went to R , to a physician. He found " the uterus 

hardened at the neck and too low in the vagina." He first gave 
me a violent emetic, used electricity, had my whole body daily 
rubbed with No. 6, and like stimulating liniments, and put a 
Banning's body brace upon me. I took a great deal of macrotin, 
tonics, etc. His treatment, which continued several months, 
improved my general health more than any I had had. Yet my 
menstrual flow did not come right. Finally, he one day ran his 
fingers violently through his hair, and said "he could not see 
what did ail me." 

I went home discouraged, and again did without medical aid 
for two years more. Indigestion, cold feet, rheumatism, attended 
by the whole train of disorders of the nervous system, had been, 
and was, my constant experience. I rarely ever had any pain in 
my head or spine, after the first year of my married life. A nat- 
urally gay temperament, a great love of fun, horseback riding (of 
which I was very fond), carriage driving, travel a part of every 
year, with never any very laborious household duties, probably 
kept me from becoming a bedridden invalid. 

On removal into the city of C I again sought professional 

treatment. I had then been married six years. Faithful adher- 
ence was made to injections of rose-leaf tea, and numerous other 
local remedies, and a gold pessary was introduced. Finally, after 
nearly two years of constant treatment, it was satisfactorily dis- 
covered that I had " rheumatism of the womb." I was under 
the care of this physician for six years, and took a great deal of 
medicine — I think considerable quantities of gum guaiacum in 
brandy. 

The year of 1865 I traveled in Europe, and some in our own 
country. I have always borne travel well, enjoyed it thoroughly,. 



ON THE DISEASES OF WOMEN. 185 

and fellow-travelers seldom have discovered that I was not in 
health. 

In February, 1868, I removed to Chicago. The cutting winds 
affected me so that in less than three weeks I dreaded to go out 
of doors — they seemed to search my very bones. A thirst which 
could not be satisfied soon set in, and, shortly, a retention of 
urine, with rheumatism in my whole right side. I was very sleep- 
less. The atmosphere seemed too cold for me to breathe, and I 
was obliged to cover both head and ears to get sleep at all. I 
found temporary relief in short, repeated visits to Cincinnati and 
Springfield, Illinois. In May I had several large carbuncles, 
during which my indigestion and other difficulties were much 
relieved. About this time I frequently felt sharp pains about my 
heart, and sometimes a sense of dizziness, which soon left me if 
I laid down for five minutes. I often would catch my breath in 
going about in common employments, and drew long, deep sighs 
in my sleep. I was nervous and wretched — and the monthly 
period was attended with increased suffering. 

In July I went to the sea shore, as had been my custom for 
several years, and from which I had always returned in much 
more comfortable health. The weather during the journey was 
exceedingly hot, the warmest known for years. On reaching 
Philadelphia by a morning train, with scarcely a dry thread upon 
me from perspiration, I found my body covered with rash or 
prickly heat, which I had not seen for eighteen years. It did not 
wholly disappear at once. I had passed through the catamenial 
period just before leaving home. We reached the sea-side, and 
the sea-breeze was, as usual, invigorating and refreshing to me. 
I bathed for one week. I was very fond of swimming, but found 
the exercise too severe for me, and, this time, could not practice 
it at all. On retiring one night I found a steady pain in my left 
breast. I took little notice of it, supposing it to be caused by 
indigestion, or pleurisy. It often awakened me during the night, 
but by putting my hand on the spot and warming it, I dropped 
to sleep. Next morning I folded a flannel several thicknesses 
and put over it, dressed, and ate my breakfast, as usual. Soon 
after breakfast I was seized with the pain most violently, and 
seemingly in the region of the heart. In ten minutes I was pros- 
trate. A mustard plaster applied increased my suffering fearfully. 
Dr. B., of Philadelphia, was summoned, and a young physician 
was present. Dr. B. at once pronounced the attack "rheumatism 
of the heart." The pain once suddenly went to the bladder, 
causing excruciating agony. A very copious discharge of urine 
soon followed, and the distress was again in the heart. I was 
relieved by aconite. In two weeks, at Dr. B.'s urgent advice. I 
was taken to Capon Springs, Hampshire county, Virginia. This. 



186 LECTURES, CLINICAL AND DIDACTIC, 

spring is celebrated for its use in " the different forms of dyspep- 
sia, and as a remedy in gravel its virtues are said to be unques- 
tionable .' while externally applied in the shape of cold or warm 
baths, its results " are proved beneficial in rheumatism and diseases 
of the skin.'' I spent three weeks here, and my heart was 
entirely relieved ; but, after leaving, I was again attacked, in 
about a week, in the city of Brooklyn. The medical attendant 
there never said what he thought my disease was, but " supposed 
my trouble proceeded from the spine." He was positive there 
was no disease of the heart. 

All the physicians said I must not return to the climate of 

Chicago, so I went to my relatives in the west, to R , where 

I was attended by a physician two months. There was a great 
deal of soreness to the touch about my heart, with constant, 
severe pain, and I could not endure a breath of outside atmos- 
phere, though it was only the first of October. He said I had 
"angina pectoris," and "hydro-pericardium." I had noticed I 
suffered more with my heart about the time the menses made 
their appearance — generally a few hours before, and I asked him 
to find whether there was not something wrong in connection 
with the uterus, as I had had no attention to that organ for five 
years. He made examination and told me I " was all right 
there." 

Suppose we recapitulate the chief points in this case, which our 
patient has detailed in so interesting and truthful a manner. Her 
first menstruation was prompt, plentiful and painless. One year 
later, amenorrhcea (suppressio mensium), from cold and wet feet. 
At sixteen inordinate appetite, the rash declining — sudden and 
severe illness from repercussion of the eruption, which did not 
reappear for many years — inveterate and inexplicable nervous 
symptoms. After marriage, at eighteen, menstruation normal for 
three months — then seven weeks' interruption — "female pills" 

— illness. After this, painful menstruation each month — another 
physician, diagnosis of retroversion with ovarian tumor — blisters 

— purgatives, etc., for a year — apparent rheumatism in the right 
limb, worse on standing, relieved by warmth and rest in the 
reclining posture — was a confirmed invalid at twenty, but dis- 
abled only for the first few hours of the " period" — abandoned 
all treatment for a year or two, and improved in consequence — 
another doctor ; diagnosis, induration of the cervix and prolapsus 

— emetics, electricity, friction, an abdominal harness, macrotin 
tonics, etc., — improvement of general health, but the menstrual 



ON THE DISEASES OF WOMEN. 187 

disorder unchanged — the doctor at his wits' end — abandoned all 
treatment for two years more — nervous disorders continue — still 
another physician — two years treatment and a diagnosis of 
''rheumatism of the womb" — continue treatment four years 
more (six in all) — with a faithful trial of Dewees' prescription 
of guaiacum — 1865 in Europe — 1868 removed to Chicago — 
prairie winds in spring unfavorable — critical and salutary boils 

— increased cardiac trouble — rheumatism of right side — monthly 
symptoms worse — goes to the sea-shore in July — after a copious 
perspiration the eruption, which had not been seen for eighteen 
years, makes its appearance — cardiac paroxysms at night and 
next day — alternation of rheumatic pain in the heart and bladder 

— relief from aconite — the mineral springs improve the heart 
symptoms — one more doctor and another diagnosis. 

The additional particulars, of clinical interest, which were given 
me when I took charge of this case, are the following : 

About five months after her marriage she commenced passing 
membranous shreds, and since then has never escaped more than 
two consecutive "periods" without them. The size and firmness 
of the shreds vary at different times, but they are not larger, nor 
is the suffering relatively greater at the next period, after passing 
one month without them. The degree of pain and discomfort 
vary with the presence or absence of the membrane, and also 
with the amount of exercise taken at the time the flow commences. 
If she lies in bed for a day or so, there is little relative suffering. 
Although she had frequently spoken to her physicians of these 
membranes, only one had concerned himself about them, and he 
had decided, in an off-hand way, that they were the result of a 
miscarriage. None of them ever made any inquiry with respect 
to the character of these products, and until I procured this first 
specimen for microscopical examination, no one, except the patient 
and her husband, had ever seen them. 

Upon careful inquiry, I learned that she suffered at times, 
usually some hours in advance of the flow, from a circumscribed 
pain in the right ovarian region. She could cover the spot with 
the tips of her three fingers. The pain would radiate somewhat. 
and extend thence along the limb. It was invariably worse in 
damp weather and after exercise. 

While the cardiac symptoms were more or less constant, they 
were greatly aggravated at the month. Indeed, her sufferings at 
this time were extreme and alarming. She had discovered that 
aconite 2nd would relieve this distress in a very few minutes. 
but disliked to take it on account of unpleasant symptoms, which 



188 LECTURES, CLINICAL AND DIDACTIC, 

almost invariably followed some hours after. The chest had been 
most carefully wrapped in flannels. The slightest change in her 
clothing or exposure resulted in her taking cold and in an increase 
of suffering. Daily and prolonged friction, with stimulating lini- 
ments, had been resorted to in order to keep the blood in motion. 
The spine was exceedingly sensitive to pressure throughout its 
whole extent, for the relief of which porous plasters had been 
worn almost constantly for months. 

I found the uterus so prolapsed that, unless it was supported 
by a sponge, pessary or tampon, which she had worn habitually 
for years past, she could not stand or walk. With this deviation 
of the womb there was more or less of strangury, which at time& 
annoyed her exceedingly. She has never borne any children. 

This case presents some striking practical facts. It illustrates 
that one physician, and sometimes a number of them in turn, may 
be deceived concerning the nature of the disease which they have 
been called upon to treat. It shows how the reflex and secondary 
phenomena dependent upon uterine disorder may mislead the 
practitioner ; and how apt the most experienced in our ranks are 
to overlook the most important symptoms, while at the same time 
they put great stress and emphasis upon such as are merely 
incidental. 

Membranous dysmenorrhea is a rare affection, and, when it 
does exist, is very apt, as in this case, to have continued for some 
years before being recognized. In exceptional 
locked 6- may be ° ver " cas es, it occurs in young girls, but is usually 
met with in married women. In the majority 
of instances it begins soon after marriage, when it is accompanied 
by such slight symptoms as to be deemed of little consequence. 
Under these circumstances, it is usually regarded as the sequence 
of an early abortion. 

We have to confess that the special pathology of this disease is 

not very well known. Dewees and others have taught that it 

occurs most frequentlv in women of a rheu- 
Causes - .,.,-.•« -,.. •• i 

matic diathesis, home authorities insist that 

the membranous formation, which is its chief characteristic, is 

always the product of conception. But this cannot be true, for it 

may occur in the virgin, and also in those who have for many 

months abstained from sexual intercourse. It is the commonly 

received opinion that, while in its beginning it may date from a 



ON THE DISEASES OF WOMEN. 189 

miscarriage, the continuance of the complaint is not necessarily 
connected with conception. 

Others hold that the membranous product results from uterine 
inflammation. Upon this theory a recent author proposes to style 
the disease " endometritis epithelialis." But it is not of the exfo- 
liation of the epithelium merely that we are speaking. That may, 
and often does, occur in healthy menstruation. Oldham and Tilt 
refer the exfoliation of this membrane to the morbid influence 
exerted upon the lining membrane of the womb by disease of one 
or both of the ovaries. In rare instances, it may originate in 
syphilis. Sometimes it is related to a cutaneous eruption which 
has been repelled from the surface, with the appearance of which 
its symptoms seem to alternate. 

Here are two excellent specimens of the membrane which this 
patient has expelled with the menstrual flow. Let us examine 
into its anatomical peculiarities. The old au- 
of^hfmSan" uKarities tnors thought it to be a kind of croupous 
deposit upon the uterine surface. They talked 
wisely, as some surgeons do in our day, of the spontaneous organ- 
ization of coagulable lymph into a pseudo-membrane. Dewees 
even suggested that these membranes might be formed from the 
lymph contained in the menstrual blood. 

If we compare this membrane with the decidua vera in the 
early weeks of pregnancy, we shall discover an exact correspond- 
ence. It is triangular, smooth within, and 
^identical with decidua ^^g^ an d villous on the outer surface. If the 
entire cast has come away, or if we can place 
the shreds together properly, we shall find the three orifices cor- 
responding with the internal extremities of the Fallopian tubes, 
and the os internum of the uterine cervix. Moreover, here are 
numerous little openings through which the utricular glands have 
discharged their product. The microscope proves these mem- 
branes to be identical in structure. And their histological elements 
are precisely the same as those of the uterine mucous membrane 
also. 

It is undoubtedly true, therefore, that the decidua menstrualis. 
as Virchow named it, is not a new or heterologous membrane 
which is formed and expelled the womb at each menstrual period, 
but the altered lining of that cavity, which has been cast off by 
a species of physiological moulting. 



190 LECTURES, CLINICAL AND DIDACTIC, 

Now, inflammation is not a factor in the organization of the 

clecidua menstrualis, any more than in that of 

d In Jj mmatio11 Is accI " the clecidua vera, or the outer envelop of the 

embryo. It is, indeed, incidental to both these 

processes, but it is not necessary to either of them. 

There is, therefore, something plausible in the theory of Old- 
ham, that ovarian influence has much to do with the frequent 
exfoliation of the uterine mucous membrane in 
oidham's theory of ova- ^g c i ass £ su b/jects. In case of conception, 

nan influence J ■»• 

this influence undoubtedly initiates those 
changes which finally develop the clecidua vera before the fecun- 
dated ovum has dropped into the uterine cavity. And do you not 
perceive that a slight perversion of function in the ovaries may 
induce a similar physiological change in the uterine textures as a 
contingent of menstruation? In the former case, the egg is 
retained throughout the period of gestation, and finally extruded 
at term. In the latter, it must escape, with its accompanying flow, 
as soon as practicable. In both, the deciduous wrapper is sooner 
or later expelled. 

This view has its confirmation in such clinical facts as the fol- 
lowing : When the "period " sets in, the ovaries are often found 
to be swollen, tender, and the seat of discom- 
fort. In a majority of cases there is considera- 
ble pain in one ovarian region (usually the left), which persists 
until after the escape of the flow, and of the shreds also. Grailly 
Hewitt is quite emphatic on this point and its significance :* 
" There is often pain in one or other ovarian region; and it ap- 
pears reasonable to conclude that in some way or other this pain 
is connected with the formation of the membrane. The intimate 
functional relation between the ovaries and the uterus lends sup- 
port to the view that in a morbid condition of the OA r ary — a 
functional perversion, so to speak, of its influence over the uterus 
— we have an explanation of this abnormal occurrence." 

The single pathognomonic symptom of this disease is the dis- 
charge at the menstrual period of such a membrane as is shown 
. . , . you in this specimen. Sometimes, although 

Clinical history. . . 

rarely, it comes away in the form of a sac, or 
complete cast of the uterine cavity, in which case it may be mis- 

* The Diagnosis and Treatment of Diseases of Women ; London, 1863 ; p. 479. 



Its clinical confirmation. 



ON THE DISEASES OF WOMEN. 191 

taken for a mole. Usually, however, it is in shreds and pieces, 

which vary in size from that of your thumb nail 

shape and size of the £ ^ w0 or three square inches. These pieces 

membrane. J- -t 

may be so regularly formed that you can place 
them together in such a manner as to be certain from the triangu- 
lar shape of the mass, as well as from other characteristics, that 
the womb has been stripped of its lining membrane throughout. 
In some cases a very considerable quantity of this menstrual 
decidua is thrown of. 

It may happen that this membrane will be seen but once in the- 
same patient. Or it may be observed each month regularly in 

others. Sometimes it appears at alternate 
Regularity of its appear- m0 nths, and again only once in three months. 

ance. * o J 

In the case which I have just detailed, my 
patient did not for many years pass more than two consecutive 
" periods" without their being present. And this under every 
variety of climate and external circumstance. 

The subjective symptoms vary in different cases. Beginning 
usually with a delay in the appearance of the accustomed men- 
strual flow, the suffering is analogous to that in 

Its expulsion. . . 

an early abortus, and in other varieties of clys- 
menorrhcea. Subsequently it will be modified by the condition 
and susceptibility of the patient, as well as by the size of the 
membrane to be extruded, and the ease of dilatation of the cervi- 
cal canal through which it must pass. Some women suffer as 
severely as they would in labor at term. As I have already said, 
the ovarian pain is seldom lacking. One of my patients finds her 
suffering greatly mitigated by lying in bed for one or two days 
when the " period " arrives. And the patient whose case is under 
review has remarked that, when she ate very lightly, the men- 
strual suffering was very much lessened. In her experience, a 
hasty meal taken immediately before the catamenial flow occasions 
extreme suffering. Scanzoni reports that two of his patients 
" could always say, with perfect certainty, one or two weeks be- 
fore the return of the courses, whether or not they would pass 
membranes. Every time that this was the case they experienced 
for one or two weeks previously, a sharp, pinching pain in the 
umbilical region." 

The quantity of blood discharged in such cases is in excess of 



192 LECTURES, CLINICAL AND DIDACTIC, 

that proper to health}' menstruation. This can be readily explained 
as the consequence of detaching the lining 

The ' flow ' proper. , « .<. -, n , 

membrane ot the womb trom a sub-mucous sur- 
face which is unusually vascular. It corresponds in every way 
with the haemorrhage incident to abortion prior to the formation 
of the placenta. Sometimes the flow is profuse and alarming, but 
as a rule it is held in check by the contractile efforts of the womb 
to dislodge and expel the membrane. When this has escaped, it 
usually, but not always, ceases. Where some small shreds are 
retained, there is danger of subsequent loss of blood. In women 
of an hemorrhagic diathesis, the flow may degenerate into a pass- 
ive haemorrhage and continue during the inter-menstrual period. 
In case the decidua menstrualis is not cast off, but remains until 
the next month, as sometimes happens, the flow may be scanty in 
amount at one period and copious at another. 

The reflex nervous symptoms which are present in this form of 
dysmenorrhoea vary in different persons. In some the stomach is 
the focal point of disorder, and a most intracta- 
ble vomiting results. Our patient has suffered 
from this symptom for nearly a fortnight at a time. In others, the 
greatest care is requisite to avoid severe fits of indigestion. A 
majority of these patients are habitually costive. 

If she is of a rheumatic diathesis, the cardiac symptoms may be 

so pronounced and so clamorous as to lead to the belief that the 

heart is the real seat of the difficult}'. It was 

Reflex cardiac symptoms. . . 1 

this state ot things which induced my prede- 
cessors in the management of Mrs. 's case to form an incor- 
rect diagnosis. In the frequent recurrence and severity of her 
paroxysms of dyspnoea, the palpitation, cardiac pain, oppression 
and perturbation, there were evidences of functional derangement, 
but of nothing more serious. The doctors must have drawn on 
their imagination for the physical signs of organic disease of the 
heart. At least, I have examined her repeatedly, and most care- 
fully, without being able to discover any lesion of the valves, of 
the pericardium, the endocardium, or of the parietes of the heart. 
Moreover, as soon as she was put upon the remedy which was ap- 
propriate for the relief of the menstrual disorder, the cardiac 
symptoms vanished. 

You should bear in mind that the remote symptomatic affections 



ON THE DISEASES OF WOMEN. 193 

of the heart, and of other organs, which are dependent upon 
uterine disease of whatever variety, are invaria- 

Practical deductions. . 

bly aggravated at the month. Indeed, m most 
cases, they intermit and return as regularly as the menses them- 
selves. Independently, therefore, of the presence of the decidua 
menstrualis, this one circumstance would have led any one of you 
to infer that in this case the heart symptoms were reflex, and not 
idiopathic. It is true, however, that organic disease of the heart 
may finally result from such an indirect cause, when that cause is 
in almost constant operation for many years. But such cases are 
exceptional. 

As in other forms of dysmenorrhoea so in this, uterine displace- 
ments, more especially prolapsus and retroversion, are very apt to 
result. In some cases the most obstinate and 
tio ( ns risequentuterineaffec " distressing anteversion has been caused by mem- 
branous dysmenorrhoea. Either and all of these 
deviations increase the difficulty and embarrass the treatment. 
Fibroids, polypi, metro-peritonitis, endo-metritis, and endo-cervic- 
itis, are also coincident diseases. 

You would diagnosticate a case of membranous dysmenorrhoea 
from one of abortion, by the regular return of the monthly period, 
by the membrane usually coming away in 
^Diagnosis -from abor- s hreds, or if it were entire, by the sac contain- 
ing no rudiment of an embryo or of other mem- 
branes enclosed within it, and by the perforated, sieve-like appear- 
ance of the membrane itself. These symptoms, however, are not 
positive, for the patient might abort exactly at the first month ; 
or, because the ovum is sometimes dissolved, the sac might be 
empty. But it would be quite extraordinary and unprecedented 
for one to abort each month regularly. 

The only danger is from concomitant disorders. The patient 

might possibly die from hemorrhage, but that would be very rare. 

A continuous and copious loss of blood might 

Prognosis. . .. 

so undermine the general health as ultimately 
to endanger life. Or real organic disease of the heart, lungs or 
stomach, or even of the brain or spinal cord, might finally develop 
and destroy it. In the case of patients who are approaching the 
climacteric, your diagnosis should be guarded. It is very proba- 
ble that, could they be seen at an early date in the history of the 
13 



194 LECTURES, CLINICAL AND DIDACTIC, 

disease, most cases would be curable. Sterility is an inevitable, 
but not always an incurable, consequence of membranous dysmen- 
orrhea. 

Treatment. — The proper management of this disease will draw 
largely on your skill, your professional knowledge and experi- 
ence, your tact, your deliberation, and your 

General therapeutics. 

patience, iou will have to consider the modi- 
fying influences of the rheumatic diathesis, of the abortive ten- 
dency, the ovarian disease, the repelled eruption, the reflex com- 
plications, and even of secondary disease in the uterus itself. 
There is no specific treatment which is suited to all cases of mem- 
branous clysmenorrhcea alike. An exclusive idea of its therapeu- 
tics would certainly mislead you. 

Some cases of this disease are undoubtedly rheumatic, while 

others are not. The susceptibility of our patient to the damp, 

chilling prairie winds in the spring, the fugitive 

Special therapeutics. . . . , _ 

pains m her chest and right limb, the cardiac 
symptoms, and the relief afforded to all these by removal to a 
milder and more equable climate, betray the rheumatic complica- 
tion. These and similar symptoms in one who was predisposed to 

rheumatism, would suggest such remedies as 
For rheumatic compiica- aconite, bryonia, rhus tox., nux vomica, mercu- 

tions. ' ^ ' 

rius and macro tin. Care should also be taken 
to protect the patient against the harmful influence of exposure to 
storms, or sudden and extreme vicissitudes of weather. She 
should be warmly clad, and in a measure insulated by flannel or 
silk wrappings. Above all things, the night air is especially inju- 
rious to this class of subjects. 

In a few women, the tendency to a periodical exfoliation of the 

uterine mucous membrane constitutes a species of dyscrasia. If 

these persons conceive, they are very likely to 

For the abortive dyscrasia. n . . .. 

abort; and it they do not become pregnant, 
they are fit subjects for the disease in question. This abortive 
habit is a powerful pre disponent of membranous dj'smenorrhcea. 
Most of the hints which are applicable to the prevention of threat- 
ened abortion are equally appropriate here. I need not pause to 
detail them. 

It may happen, in exceptional cases, that the character and his- 
tory of a repelled eruption will point out the proper remedy. 



ON THE DISEASES OF WOMEN. 195 

When this patient placed herself in charge of her last physician, 
she was put upon sulphur 30th, with prompt 
^incase of repelled erup- an( j ev ident relief of all her symptoms. This 
was prescribed on account of the chronic nature 
of her disease, and its manifest relation to the eruption which had 
been repelled. A few doses of apis mellifica 3d were then given 
for the ovarian pains, the urinary trouble and the cardiac symp- 
toms, and she was finally ordered calcarea carbonica 12th, which 
she is now taking. 

In so far as the reflex symptoms are concerned, there are but 
very few of them that are distinctive, sugges- 
^Reflex symptoms irreie- ^ive, or reliable. They are quite too sensa- 
tional to be trustworthy. You cannot depend 
upon them as indicating the suitable remedy, any more than upon 
a majority of similar symptoms in hysteria. 

The ovarian lesion and its symptoms are more significant. For, 
in most cases, if we can recognize and remove 
toms!" the ° varian symp ' them, we may hope to cure the menstrual dis- 
order. Apis mellifica, calcarea carbonica, pla- 
tina, belladonna, colocynth, lachesis, thuja, kali jodatum, mercu- 
rius, or hamamelis, may be appropriately and successfully em- 
ployed. 

Since we understand the origin and structure of the decidua 
menstrualis, the stereotyped advice to employ such remedies for 
the cure of this disease as are given in pseudo- 
tiot n antiquated P rescri P- membranous croup and diphtheria, would be of 
very doubtful service. For other reasons than 
those usually given, it is possible that in some cases the bichro- 
mate of potassa, mercurius jodatus, cantharis, ammonium caus- 
ticum, or even the chloride of lime, might prove serviceable. In 
a case of this disease, Dr. Mandl,*, however, applied the kali 
chlor. directly to the uterine mucous membrane, at short intervals, 
for the space of ten months. The effect was to interrupt the for- 
mation of the decidual product while he continued the applica- 
tion, but as soon as he desisted, it was formed and expelled as 
before. 

There is no evidence that local applications to the uterine sur- 

* Wiener Med. Wochenschrift, No. I, 1869. 



196 LECTURES, CLINICAL AND DIDACTIC, 

face have ever accomplished any more in this disease than in the 

case just cited. The good they do is temporary, 

Local applications are of anc i eV en this is more than counterbalanced bv 

temporary benefit. «/ 

the risk attending their application ; for you 
may take all the precautions prescribed, and yet, as a rule, they 
are not safe or advisable. 

Marriage has sometimes been prescribed as a remedy for this 
disease, but it is an unwarrantable expedient, and is very likely to 
aggravate the complaint. Conception may cure 
it, provided the patient can go to term. It may 
be indispensable to the cure that she should live absque marito. 
Or we may prescribe that intercourse shall take place only at long 
intervals. 

Very decided benefit may sometimes be derived from the em- 
ployment of the sponge-tent, with a view to dilate and remove 
any obstruction of the cervix which prevents the 
free escape of the menstrual blood. This would 
cause the womb to disgorge, unload its capillaries, relieve the 
hyperemia, avert an excessive hypertrophy of the mucous mem- 
brane, and possibly prevent its exfoliation. Moreover — and it is 
by no means an inconsiderable thing — this dilatation greatly mit- 
igates the sufferings of the patient. I applied the tent repeatedly, 
and with excellent effect, in the case of which I have now spoken 
to you at such considerable length. 



ON THE DISEASES OF WOMEN. 197 



LECTURE XI. 



MENSTKTJAL EETENTION A CAUSE OP TJTEEINE DISPLACEMENTS. 



Gentlemen : 

Dr. Rigby to the contrary notwithstanding, it is undoubtedly 
true that many examples of, uterine displacement are referable to 
other causes than external violence, morbid growths, and the 
parturient act. Among these causes there is one which has been 
almost entirely overlooked. I allude to an habitual delay or 
retention of the menses. 

A patient has dysmenorrhea. As a condition of functional 
activity, the uterine tissues are surcharged with blood, which 
moves sluggishly through them. The uterine 
th?weight n ofThJwom r b ase mucou s membrane has shed or secreted the 
menstrual product into its cavity ; but this 
product cannot pass through the internal os uteri and the canal 
of the cervix. In order to empty the womb of what should 
escape without suffering or delay, the reflex phenomena of labor 
are requisite. The increase in the blood-supply, the torpidity of 
its circulation, and the retention of the menses within the womb, 
add to its volume and weight so as to drag down and displace it. 

Whether the dysmenorrhea be congestive, obstructive, ovarian, 
spasmodic, or membranous, the consequence is a stasis of blood, 
and incidental suffering and disease. The proper balance between 
supply and waste, whether as respects structural repair or secre- 
tory demand, is lost. Textural changes in the inferior segment 
of the womb and in the cervix are almost certain to follow. The 
infiltration of the tissue may result in induration, hypertrophy, 
neoplastic growths, or unnatural adhesions. 

In such a case the displacement is, perhaps, active and tempor- 
ary. It may alternate with almost perfect health, and return with 



198 LECTURES, CLINICAL AND DIDACTIC, 

each menstrual cycle, to be relieved by the flow. It is not 
unusual for patients to complain of symptoms 
mSith placements at the that are ^ ue especially to prolapsus or ante ver- 
sion, whenever they menstruate. Many women 
learn from experience that much of the suffering incident to dys- 
menorrhcea may be relieved by raising the hips and lowering the 
head. One of my patients told me that for years she had derived 
more comfort at such times from placing her feet upon the high 
foot-board of her bed, and dropping the head very low, than 
from anjrthing she had ever taken internally or used locally as a 
palliative. 

More frequently, however, and for reasons already specified, 
the luxation becomes chronic. The monthly period recurs so 
soon that the patient has not recovered from 
and^vh^ 600 " 16 chronic, one attack before another is precipitated upon 
her. It is like attempting to cure an acute 
gastritis while the patient continues to eat regularly and heartily 
of indigestible food. 

Nor is the mere increase of weight in the womb the sole cause 
of the uterine deviations which are incident to dysmenorrhcea. 
The more decided and powerful the expulsive 
utSus Ulsive effort ° f the P anis (which are designed to force the flow), 
the greater the liability to displacement ; just 
as in labor at term the uterus descends in ratio with the strength 
and persistence of its contractile effort, and may even escape the 
vulva without first being delivered of its contents. And this is a 
veritable labor. There are the same contingents of structural 
change in the uterus, and of relative displacement of the organ, 
that attend upon abortion and full term delivery. The difference 
is one of degree, and not of kind. 

. Amenorrhea (suppressio mensium) sometimes results in uterine 

displacement. This is especially true of those cases in which 

certain kinds of exposure or exercise have 

Uterine displacements A 

irom temporary suppres- arrested the flow at the moment it was due. 

sion. 

If a woman sets out for a sea voyage, or a 
voyage by rail, the day before her menses should appear, she will 
be very apt to skip one period, and perhaps more. Or, if the 
flow comes, she may experience greater suffering than usual. If 
it be too scanty, or too profuse, she may be very ill. As an indi- 



ON THE DISEASES OF WOMEN. 199 

rect consequence, she will be likely to suffer from some form of 
uterine flexion or dislocation. 

There is no question but that many cases of this kind are due 
to such slight and apparently trivial causes. It may be as harm- 
ful and injudicious for some women to leave 

Carelessness at the month. , » . . , , 

home on the eve 01 menstruation as it would 
be for others to go to church or to a concert when in momentary 
expectation of childbirth. I have known a rough ride in the 
carriage or upon horseback, taken at this particular period, to 
cause a decided prolapse of the womb. And in the nature of 
things, there is no reason why it might not frequently happen. 
According to Wright, " a displacement of the uterus is just as 
much an absolute fact as the occurrence of a hernial protrusion," 
and hernia has certainly resulted from a similar cause. 

I do not wish to be understood as teaching that all, or even a 
majority of cases of uterine displacement are chargeable to men- 
strual obstruction or derangement. I only insist that this class 
of causes and their manifest consequences shall not be overlooked. 
The truth is that our writers and practitioners are accustomed 
to magnify the importance of hygiene as applied to gestation, 
while they make but little account of that proper to menstruation. 
In so far as uterine deviations are concerned, we are prone to 
discriminate loosely in favor of those sequelae which may follow 
the parturition of the embryo and foetus, and to discard all such 
as are consequent upon that of the menstrual product. 

Treatment. — If this view is correct, the inference is obvious. 
The cure of this kind of displacement must hinge upon the relief 

afforded to, and the regularity of, the men- 
thJmensfruai dr s order Cure strual process. If the dislocation, of whatever 

variety, depends either upon dysmenorrhea, or 
simple retention of the menses, the first thing to be done is to 
remedy the catamenial disorder. To treat the case simply as a 
diaplacement, and to expect to cure it by any universal expedient 
whatever, whether local or internal, will be unsatisfactory and 
unsuccessful. Emmenagogues would only increase the difficulty. 
And so also would astringents. The pessary would be of no 
more service in such a case than a hernial truss. Indeed, it might 
prove as harmful in a displacement arising from this cause as it 
has been beneficial in others. 



200 LECTURES, CLERICAL AXD DIDACTIC, 

This theory explains the wonderful efficacy of some of our 

remedies, when prescribed for the relief of uterine luxations. 

Through their manifest and well known rela- 

Modus operandi of some ^ 011 ^ ^q mens trual function, we have learned 

remedies lor prolapsus, etc. 7 

to rely upon them for the cure of those dis- 
placements of the womb that are consequent upon certain 
derangements of that function. In other words the key to their 
curative range and adaptability is found in their power to remove 
the condition upon which the disorder of place depends. From 
the provings alone we might never have learned what we already 
know empirically, logically and physiologically, of the power 
of certain remedies indirectly to influence the position and rela- 
tions of this very important organ. 

There is an excellent and harmless auxiliary which can be used 
in some of these cases to great advantage. I allude to the sponge 

tent, which by removing the mechanical cause of 
iui T a h u e xiifa°r^ e tent a " se " the retention, may relieve the difficulty and help 

to cure the displacement. I am not aware that 
others have recommended this instrument in any form of uterine 
luxation. But it is a temporary, non-medicinal, unobjectionable 
expedient, which can be employed without risk, and in such a 
manner as to secure the free exit of the menstrual fluid as soon 
as it is poured into the uterine cavity. It certainly does not inter- 
fere with the action of internal remedies, nor will it, if properly 
applied, give rise to any lesion of the cervix. It promotes the 
painless and gradual dilatation of the internal os, obviates suffer- 
ing, and averts the reflex symptoms of which the patient is so apt 
to complain. It does not lift the womb directly, but ministers to 
its reposition by unloading its vessels, so that it can retract. It 
should be introduced from twelve to twenty-four hours in advance 
of the menstrual period. At this time the internal os is " off- 
guard," and the operation is less painful and more successful. It 
should be allowed to remain in for from four to eight or ten hours 
according to circumstances. When it is removed, the patient 
should keep to the bed or sofa, and not be allowed to stand upon 
her feet for some hours, or even, perhaps, for days. 

It is a singular and significant fact that cases of dysmenorrhea 
which merge into menorrhagia are rarely followed b}^ uterine devi- 
ations of any kind. It is only when the absolute loss of blood 



ON THE DISEASES OF WOMEN. 201 

causes extreme atony of all the utero-vaginal tissues that such a 
result is witnessed. 

UTERINE COLIC. 

Case. — Mrs. sent for me in haste, on account of her sud- 
den illness. She had reached home from a long journey, and in 
perfect health, only an hour before. After a general bath, she 
took a vaginal injection of cool water, and, almost immediately,, 
felt a sharp, spasmodic pain in the region of the womb. This pain 
increased in severity, and, before my arrival, became almost insup- 
portable. It would remit, and then return with redoubled vio- 
lence. I found her pale, with a cool surface, an anxious, implor- 
ing expression of countenance, and a slight nausea. She was 
midway in the inter-menstrual period, and had not eaten anything 
unusual, or, indeed, anything whatever, for some hours. 

A clinical lecture without a practical lesson would resemble a 
sermon without a moral one. There is a point in this case which 

you should carry home with you. It is this, 
time?infurio J us Ctions some " tnat there are certain conditions of the womb 

and other pelvic viscera in which the shock of 
an otherwise harmless injection thrown into the vagina may work 
mischief. Whatever determines the blood to these organs increases 
the risk of using such an expedient suddenly, and, as it were, 
without proper warning and delay. A woman has been at work 
with a sewing machine for some hours consecutively. Having 
finished her task, she takes a bath, and directly afterwards a vag- 
inal enema. Almost immediately she is seized with symptoms 
resembling those from which my patient suffered. Or a similar 
result may follow a ride on horseback, or in the carriage, a game 
of croquet, standing for an hour or two at an evening party, too 
long a walk, a protracted lesson at the piano, or, as in this case, q 
fatiguing journey, all of which acts predispose to irritable condi- 
tions of the uterus. Under these circumstances there is an exalted 
sensibility of the organ, and it may happen that a single injection 
of cool water brought into contact with it suddenly will act as an 
exciting cause of pain and disease. 

The same is true of cool or cold injections per vaginam before 
the menstrual flow has entirely ceased. And likewise also of sim- 
ilar injections taken immediately after coitus, with a view to pre- 
vent impregnation. At such periods the capillary system of the 



202 LECTURES, CLINICAL AND DIDACTIC, 

whole generative intestine is surcharged with blood. If we wait 
a little, this physiological afflux is removed, the erection of the 
organs subsides, and the proper vascularity is restored. But if we 
shock the delicate structures in the manner of which I have 
spoken, we must expect that, sooner or later, they will become 
diseased in consequence. 

In uterine colic the pain usually intermits. Sometimes thepar- 
oxj^sm returns with almost as much regularity as the after-pains 
which torment multiparas, and which it is said 
to resemble. Or it may remit and not leave en- 
tirely between the more aggravated periods. The suffering is 
referred directly to the uterine region, although it sometimes radi- 
ates into the sacrum, and again into one or both groins. It is 
characteristic of this pain that it may be in a measure and some- 
times entirely relieved by pressure. The attack commences and 
terminates abruptly, and is not preceded or accompanied by any 
particular constitutional symptoms, as chill or fever. There is 
more or less of tympanites, which develops very rapidly and dis- 
appears as suddenly. There is usually considerable intestinal flat- 
ulence, distension and pressure. This bloating of the abdomen 
lias all the characteristics of hysterical tympanites. Nausea is a 
frequent symptom in severe cases. 

The attack may continue for a few minutes only, or may extend 

through some hours, or even days. If it depends, as it sometimes 

does, upon uterine displacement, it may not 

Duration of the attack. . 

subside until the organ is restored. If it is due 

to the presence of coagula, or other foreign bodies in utero, it will 

only cease with their expulsion. In this case the pains resemble 

cramps, are expulsive, and labor-like. 

Women who are subject to dysmenorrhcea are likely to have a 

mild form of uterine colic upon slight provocation. Such persons 
may be seized with it while walking in the 

^incident to dysmenor- s t ree t, and be obliged to sit down or bend them- 
selves almost double for a few moments, until 

the paroxysm passes off. Or the pain may be so severe as to cause 

fainting and great alarm. 

Emotional causes often give rise to it in hysterical persons. With 
this class of patients a fit of answer or iealousy 

Incident to hysteria. *■ ° ** J 

may bring on the attack at almost any time. 
Or it may precede menstruation and worry the patient for some 



ON THE DISEASES OF WOMEN. 203 

hours or days in advance of the flow. Although usually amiable, 
she will become petulant, is disgusted with and distrustful of 

humanity in general, and of the male sex in 
^May precede menstrua- particular. Sometimes she is in a mellow or 

pathetic mood, or she has a fitful religious mel- 
ancholy, or, what is still worse, is possessed with the insane idea 
to work, to set her room to rights, and the plants, the birds, the 
books, the pictures, stoves, chairs and furniture must be squared 
up and cleaned up instanter. She must do an immense amount 
of work in a short time, and only in so doing can avoid this tor- 
menting species of colic and ill feeling in the uterine region. 
After which, when the flow sets in, she is exhausted, fitful, capri- 
cious, cross, tempestuous, drums on the piano by the hour, or 
writes explosive letters to her husband, or friends, and regulates 
everything with the utmost irregularity. 

Extraordinary fatigue of body or mind may induce it. Intel- 
lectual, cultivated women, are more prone to it than others. 

Seamstresses, young ladies in boarding-schools, 
Most frequent among in- actresses, and those whose minds are harassed 

tellectual women, ' 

with family cares, or who are victims of the 
social fret and friction which wear out so many valuable lives, 
suffer much from this painful disorder. 

Not unfrequently it arises from incompatibility in the marriage 
relation. Circumstances which develop a loathing of the sexual 
act, are very apt to produce it. It may originate either from im- 
moderate indulgence, or from being deprived of accustomed inter- 
course. I have known it to be caused by drinking ice-water while 
menstruating. 

Uterine colic is also incident to the neuralgic diathesis. It may 
alternate, or be complicated with ovarian neuralgia, hysteralgia, 

and even with rheumatism of the womb. In 

In neuralgic subjects. .. , . , , 

women who are thus predisposed, whatever 
causes an irritable state of the uterus may bring on an attack of 
the colic. This form of the disease is very apt to seize upon nerv- 
ous and delicate patients during the period of pregnancy. 

Treatment. — Proper hygienic precautions will doubtless sug- 
gest themselves to your minds. You should 
t . Hygienic and prophyiac- W arn the patient of the possible consequences 
of vaginal injections at improper times. And 
also of the ill effects of rude and violent exercise, whether of body 



204 LECTURES, CLINICAL AND DIDACTIC, 

or mind. If she is intelligent — and your merits will commend 
you to this class of patients especially — explain the modus oper- 
andi of those very common causes of disease and suffering among 
women. One good, logical reason will have better and more last- 
ing effect upon her than any amount of scolding and fault-finding. 
A good prophylactic is to have the patient wear an extra layer of 
flannel, silk, or cotton batting over the abdomen habitually. 

Various palliatives have been recommended to put an end to the 
paroxysm. Among the more ordinary and available of these is 
the application of towels or flannels that have 
been dipped in hot water, mustard water, hot 
brandy and water, and the like. In some cases, a sinapism will 
cause the pain to vanish in a very few minutes. Bags of hot salt, 
or of dry bran heated thoroughly, are especially useful in case of 
menstrual colic, and of uterine colic following abortion. In hys- 
terical subjects, the ether spray may be thrown upon the hypo- 
gastrium. In inveterate cases, the vapor of chloroform has been 
injected into the vagina. Dr. Simpson advised a similar applica- 
tion of carbonic acid gas. When complicated, as it sometimes is, 
with vaginismus, I am in the habit of prescribing a vaginal injec- 
tion consisting of chloroform one drachm, olive oil and glycerine 
each two ounces. Or the same may be applied by means of a cot- 
ton tampon. If the attack is incident to delayed menstruation, 
the warm sitz-bath may afford the desired relief. 

In the majority of cases, belladonna or atropine answers every 

purpose. This is especially true if the attack has been caused by 

the shock from vaginal injections taken at im- 

Internal remedies. ° 

proper times. If the case is manifestly neu- 
ralgic, and more particularly if it is complicated with ovarialgia, 
the valerianate of zinc may be indicated. 

Other remedies are colocynth, ignatia, caulophyllin, cocculus, 
chamomilla, nux vomica, pulsatilla, sabina, and secale cornutum. 

POST-PARTUM ULCERATION OF THE WOMB. 

Although ulceration of the womb is not usually classed among 
the sequelse of labor, there is little doubt but that it sometimes 
occurs in this connection. 

Case. — Mrs. , aged 28, has an infant five months old. She 

nurses the child, which is thrifty, and lives exclusively upon the 



ON THE DISEASES OF WOMEN. 205 

breast. The mother is not well. She has not menstruated since 
her confinement. She complains of aching in the loins, weariness 
on very slight exertion, pain in the left iliac region, with inability 
to lie upon her left side, malaise, anorexia, frequent headache, 
occasional strangury, and a leucorrhcea which at times weakens 
her very much and increases the old pain in the back. These 
symptoms began during her lying-in, and have continued until 
now. 

An examination with a speculum discloses a simple suppurating 
ulcer within and around the external os uteri. 

When uterine ulceration occurs in women who have but recently 

been confined, it is very apt to be overlooked. The patient may 

have escaped the perils of childbirth, but for 

Likely to be overlooked. , i i -i • • 

some unknown reason she has a lingering con- 
valescence. At first there may have been a considerable degree 
of puerperal inflammation, and following this a state of things 
analogous to what Trousseau styles " colliquative suppuration/' 
Lactation, is, perhaps, normal, and the other functions are intact, 
but she is extremely Aveak and reduced, and rallies but slowly. 
A month or two may have passed before she is able to make an 
excursion to the dining-room, or the parlor, and three, or even 
six months before she can take a drive. Meanwhile she has lost 
her accustomed elasticity, and life is become a burden. She 
drags around, impelled by circumstances, and the probabilities 
are that her ill health will be charged to some other cause than 
the ulceration, which dates from the birth of her child. 

In such a case the lesion of the os is undoubtedly a result of 
the inflammatory process. After delivery the uterine tissues 

readily become inflamed. This inflammation is 
tiot sequd ° f inflamma " often, but not always, of such a low grade and 

type as to develop into ulceration. And once 
the ulcerative metamorphosis is begun, it is likely to be overlooked 
and perpetuated. It is altogether probable that pressure upon 
the cervix, and traumatic injuries thereof during the labor, may 
indirectly occasion such symptoms as those of which our patient 
complains. 

If there were anything distinctive in these symptoms, they 
would be more easily and generally recognized. But, in a given 
case, we cannot know positively that a lesion of the cervix exists 
without ocular examination. Here the speculum is as requisite a. 



206 LECTURES, CLINICAL AND DIDACTIC, 

means of diagnosis as if the disease were idiopathic, and did not 
follow parturition. 

There are two general causes for this species of uterine ulcera- 
tion, or, rather, for ulceration of the cervix, occurring in women 
at this particular period. The first is the drain 
bio£d paired quality of the upon the mother's blood during gestation ; and 
the second, a similar drain through the mam- 
mary glands while she is nursing. By impairing the quality of 
the blood, and thus lowering the grade of vitality, these causes 
increase the risk of post-partum inflammation. And in such 
depraved states of the system there is but a short step from 
inflammation to ulceration of the uterine neck. The same remark 
applies to ulceration as a sequel of abortion, more especially after 
the fourth month. 

Treatment. — The hint which I have just given you concerning 

the relation between the depraved and impoverished condition of 

the blood and the symptoms complained of, is 

Weaning the child.- . .£ f ,. 

oi great practical significance. Acting upon 
it, you would prescribe the proper hygienic regulations. If you 
are satisfied that there is too much of waste and expense to the 
mother's organism in the quantity of milk that she furnishes, it is 
better to feed the child with something else than to bankrupt the 
mother's strength in this manner. Weaning is a last resort. It 
is not necessary, except in extreme cases, and where the quality 
of the milk is such that the child is finally poisoned by it. 

The diet should be as nourishing as possible. Allow milk, lean 
meats, eggs, game, fruits, and good bread and butter, instead of 

the sick-room teas, slops and kindred abomina- 

The diet. ' r 

tions. Fresh air and sunlight should also be 
ingredients in the prescription. But let me caution you to re- 
member that walking may be very harmful, in case of uterine 

ulceration, and for this reason, the womb beings 

Walking. ' ' . & 

pendulous when the patient walks, the denuded 
cervix is brought into contact with different portions of the vagi- 
nal mucous membrane. Friction irritates it, and excites the local 
circulation to such a degree as greatly to increase the suffering, 
and to extend the lesion. Moreover, the blood gravitates into 
the pelvic organs, and the consequent congestion more than 
counterbalances the good effect of the out-door air and exercise. 



ON THE DISEASES OF WOMEN. 207 

Riding is less objectionable, but I have observed that many patients 
with uterine ulceration complain seriously of 

Riding. -i 

the street-cars, the stopping and starting, as 
well as the roughness of which, worry them more than riding in 
the stages on the avenue, or in a private conveyance, if it be 
carefully driven. You would not send such patients to ride in a 
rough country wagon, neither upon horseback. 

Compared with ordinary cases of uterine ulceration, the post- 
partum variety may be more easily and promptly cured. The 
explanation of this fact is to be found in the ex- 
and u why 0mparatively easy ' emption of the menstrual return, which so much 
retards the cure under different circumstances. 
Here is no periodical determination of blood to the womb. In 
lieu thereof we have a physiological afflux of blood to the mam- 
mary glands, which is really derivative in its influence upon the 
intra-pelvic organs. For this reason, the proper treatment should 
not be deferred, else the menses will re-appear, and the cure be 
very much delayed in consequence. 

It sometimes happens that the too early return of the menses in 
one who is nursing is an evidence of debility and of waning 
strength. It may signify that the mother's force 
tat I ion nstruationdurinslac " and vitality are fast ebbing away. Much wilL 
depend upon a proper interpretation of the 
symptoms in such a case, and upon the line of treatment which 
you adopt. 

There are those who insist upon the necessity of cauterization 
in every form of uterine ulceration. They cannot divest them- 
selves of the idea that such lesions are removed 
siJrSSlatmen^ 65 ' 0111 "^ 0111 tne sphere of influence of internal reme- 
dies. They argue, and with some show of rea- 
son, that there is a lack of responsiveness on the part of the tis- 
sues which compose the uterine cervix to the best selected consti- 
tutional treatment. Some even go so far as to insist that no such 
ulcer can be healed except by topical applications, among the best 
of which are the various escharotics. 

But many physicians are in the habit of treating ulceration of 
the mucous membrane and of the integument by means of internal 
remedies exclusively. The various forms of stomatitis, ulcerated 
sore throat, chronic laryngitis, and bronchitis, typhoid fever, 



208 LECTURES, CLINICAL AND DIDACTIC, 

chronic enteritis, typhlitis and dysentery, yield to this method of 
medication. If in any of the three former affections they consent 
to apply the caustic, it is an exceptional case ; while, in the latter, 
it would be altogether impracticable to do so. 

A large proportion of cases of external ulcer need nothing more 

topically than to be protected from the irritating influence of the 

atmosphere by some bland and harmless appli- 

Only specific ulceration . • 

needs specific local treat- cation. In some cases we may facilitate the 
healing process in them by the local use of the 
same remedy that is given internally ; but, excepting in specific 
ulcers, not one in a thousand of them needs cauterization. So in 
ulceration of the os uteri — when there is no specific reason, either 
in the nature of the lesion, or in its cause and sjunptoms, why some 
specific remedy, as for example the nitrate of silver, or iodine, or 
what not, should be applied locally, your good sense and judgment 
would dictate their prohibition. 

It has been argued in advocacy of the indiscriminate local treat- 
ment of uterine induration and ulceration, that a spontaneous cure 
thereof was impossible, because of the frequent 

Arguments pro and con. . 

return and concomitants ot the menstrual now, 
the dependent position of the uterus, and the evil consequences 
of sexual excitement. But it does not follow that, because these 
cases do not get well of themselves, therefore they all need to be 
cauterized. It is bad practice to prescribe at wholesale. 

In the case before you the menstrual aggravation is not present. 
The peculiar position of the womb does not so strongly predispose 

to its vascular derangement, or to the perpetua- 

Interdiction of coitus. . _ _ _ 

tion of a chronic lesion unless the woman men- 
struates, or its tissues are undergoing the changes which are proper 
to gestation. In serious cases of ulceration of the womb, the 
worst consequences may follow a frequent repetition of the sexual 
act. Such a patient should live apart from her husband. A large 
share of the benefit attributed to the local treatment of uterine 
ulceration by caustics of all kinds should really be ascribed to the 
necessary interruption of the marital intercourse, which is thus- 
rendered impossible. The same is true, but in a qualified sense, 
of the advantage claimed for change of air, etc., by those who 
leave their homes and husbands behind them, to seek for treatment 
elsewhere. 



ON THE DISEASES OF WOMEN. 209 

You will not understand me as objecting to every variety of 
local application in simple ulceration of the os uteri. Such an ex- 
treme view would be as untenable as that which 

Allowable local treatment. , 

holds that such means, and only such, are abso- 
lutely requisite and curative. There is no valid objection to the 
topical employment of diluted glycerine, with or without the cal- 
endula, of sweet oil, or of the oleaginous collodion in the case of 
this poor woman. Either of these substances will be grateful to 
the diseased part, will serve to protect it from the injurious effects 
produced by contact of the vaginal mucus and the leucorrhoeal 
discharge, and will also stimulate the reparative process whereby 
the lesion can be healed. The calendula is especially useful where 
the purulent or muco-purulent flow, as in this case, is very con- 
siderable. It may be used as a vaginal injection morning and 
evening. 

The internal remedies that may be required will vary with the 
symptoms presented in each individual case. Chief among them 
are calendula, calcarea carb, arsenicum, sepia and sulphur. 

14 



210 LECTURES, CLINICAL AND DIDACTIC, 



LECTURE XII. 

stomatitis materna: nursing sore mouth. 

Gentlemen : 

This is one of the most interesting, as well as vexatious diseases 
with which we are acquainted. It is interesting because of its 
limited history and prevalence, its peculiar pathology, its mor- 
tality under the old regime, and the imperfect development of its 
therapeutics ; vexatious, because of its multiplied forms and com- 
plications, and its intractable nature, if not modified and remedied 
by appropriate means. 

Nature. — -Concerning the essential nature of this malady, vari- 
ous opinions have been, and are still, entertained by the profession 
at large. The most plausible of these, we 

Theories of its origin. . i • i c 

apprehend, is that which reiers its phenomena 
to a scorbutic cachexia. It has been convenient for the majority of 
medical men to attribute its origin to miasmatic influences ; to a 
diminution of the red corpuscles of the blood ; to scrofula ; to 
menstrual irregularities, antecedent to conception ; to a depraved 
and insufficient nourishment, and the like ; but the best writers 
incline to the opinion that this catalogue embraces only the crude 
outline of its causes and consequences, while it leaves the radical, 
nature of the malady itself an open question. 

That it is of scorbutic origin is evident, from the following con- 
siderations : 

First ; its causes are such as tend to derangements of nutrition 
and assimilation. 

Second ; it is invariably accompanied by anaemia. 

Third : except in degree of violence, many of its symptoms are 
identical with those of the scurvy. 

Fourth ; the same dietetic regulations are requisite to cure the 
one as the other. Both demand a pabulum largely composed of 
vegetables, and of vegetable acids especially. 



ON THE DISEASES OF WOMEN. 211 

Fifth ; they are alike mortal under treatment by excessive and 
improper medication, as by mercurials, quinine, etc. ; and this 
fatality is induced by an identical process of disintegration of the 
tissues, in which their elements are forced to remain, without 
elimination, as abnormal constituents of the blood. 

Sixth , those remedies which are most valuable in stomatitis 
materna, are also such as are most successfully employed against 
scorbutus. 

Peculiarities. — The stomatitis materna has the following 
characteristics ; It is peculiar to females, and of those to women 
during the term of utero-gestation, or at some 
iaaLrion dtogestation and P er i°d of lactation. A few writers, indeed, claim 
to have witnessed examples of this disease in 
males ; but as a rule, one would as readily anticipate attacks of 
" morning sickness/' among the latter sex (rare cases of which do 
indeed occur), as of this particular variety of stomatitis ; and in 
what follows, we are therefore to declare, and to keep in view 
the essential characteristics aforenamed. 

Symptoms. — -These may be properly classed into local and 
general. 

The local symptoms of the stomatitis materna are not subject 
to a regular order of development, but vary with each particular 
example of the disease. Their more usual 
approach, however, is as follows : The patient 
calls attention to a burning or scalding sensation in the mouth, 
which sensation is greatly aggravated by the taking of warm, 
or even of cold drinks, and by efforts to masticate her food. 
Upon inspection, the physician remarks a fiery, red appear- 
ance of the mouth, which redness is found to exist in patches, or 
diffused more or less continuously over the whole buccal surface. 
Sometimes this eruption is isolated, presenting the appearance of 
ulcerated tubercula of the size of a pea, less or more. Again the 
aforesaid patches attain the diameter of a quarter of a dollar, 
when they may degenerate into ragged and indolent ulcers, thus 
constituting the worst examples of the disease which are to be 
met with, and which frequently spring from chronic neglect, or 
from that still more deplorable cause — a dyscrasia induced by 
drugs that have been ignorantly prescribed for their removal. 

With this local inflammation, whether it be diffused or isolated, 



212 LECTURES, CLINICAL AND DIDACTIC, 

deep-seated or superficial, there are other symptoms which are 
equally characteristic. Among these there will 

Incidental symptoms. . _ . .. - 

be round a marked pallor ot the surface, 
resembling chlorosis ; a sad and dejected expression of the coun- 
tenance ; soft, flabby muscles, while the rotundity of the form 
remains as in health ; anorexia, pyrosis, and other disorders of 
digestion ; a profuse flow of saliva; the tongue is red and smooth ; 
cutting and colicky pains from the simplest ingesta ; alternations 
of constipation and diarrhoea ; strangury, with strong and scalding 
urine, which is acid to test paper ; palpitation, especially trouble- 
some at night ; the secretions are generally normal, the skin soft, 
but without any sensible perspiration ; and, if during lactation, a 
decided sympathy between the child and its parent, whereby it is 
discovered to have inherited thus early, some of her more imme- 
diate and palpable frailties. 

Chronic cases are likely to be accompanied by a diarrhoea which 
is chargeable to an extension of the specific inflammation to the 
middle and inferior portions of the alimentary mucous membrane. 
This symptom is frequently a very perplexing one, as well on 
account of the increased emaciation and debility which it occa- 
sions tiie general system, as because of its intractable nature, as 
shown in its alternating with the mouth symptoms, being better 
when they are worse, and vice versa. 

In these examples, it is not unusual to discover that all the 
mucous membranes lining the different interior surfaces of the 
body partake of this inflammation. Thus the inner coats of the 
larynx, the trachea, and of the lungs, of the pharynx, oesophagus, 
and of the whole alimentary tract, as well as of the vagina and 
urethra, are sometimes found to be separately or universally 
involved. Hence result great disturbances of function, nutrition, 
etc. ; for the destruction of the epithelial scales which marks the 
invasion of this disease upon local surfaces, interferes very 
materially with the healthy condition and requirements of those 
organs which are indirectly but more seriously implicated. 

The foregoing symptoms are liable to so frequent modification, 
both in the order of their succession and in their severity, that 
authors have fancifully described some three to five distinct varie- 
ties of the nursing sore-mouth, for which classification, practically 
speaking, there would appear to be no real necessity. We shall, 
however, consider a few of them separately. 



ON THE DISEASES OE WOMEN. 213 

Of the buccal symptoms : These are the primary and more 

palpable symptoms of the stomatitis materna. There is very 

little question, however, but that these local 

A constitutional disease. 

phenomena are symptomatic of a more pro- 
found disturbance of the general organism ; and that, properly 
speaking, we are to regard them as the certain evidence of some 
such original disorder. Examples are not wanting in which this 
disease is believed to have pursued a latent course in the system, 
during which interval, for a greater or less period of time prior to 
the development of these symptoms, it has sapped the strength 
and impaired the functional processes of the economy. 

Indeed there is every reason to believe that those cases of 
digestive and assimilative disorder, incident to utero-gestation, 
which distress and harass the patient exceedingly while carrying 
the foetus, and which, subsequent to her confinement, will not 
unfrequently result in a manifestation of the above local symp- 
toms, are to be referred solely to the existence of a latent stoma- 
titis from the beginning. These examples are perhaps as infre- 
quent as they are invincible, but in the practical experience of 
those physicians whose opinions are of value, the remark will 
hold good that it is only through a close and careful study that 
we may come to appreciate the worth of this class of symptoms, 
as affording us an index at once to their pathology and treatment. 

The peculiar characters which such symptoms present are found 
to vary with the severity and duration of the complaint. In very 
mild cases the eruption assumes more of an erythematous appear- 
ance, being diffused in patches over the sides of the tongue and 
of the cheeks. Or it may consist of common vesicles, resembling 
the aphthae adultorum of some writers, which vesicles ultimately 
degenerate into more or less troublesome centers of infection, 
each showing at its base a hardened and whitish colored ring. 
These indurations terminate either by cicatrization or ulceration. 
To this form of the complaint the name of follicular stomatitis 
has been given, for the reason that the peculiar eruption finds its 
more frequent seat in the mucous follicles of the mouth. 

In bad cases, when these vesicles burst, they develop into ulcers, 

which are either superficial or deep-seated. If the system has been 

very much depraved, and the vitality runs low, 

The local ulceration. 

these ulcers may be very numerous and ol 
large size. You will find them located on the sides or upon the 



214 LECTURES, CLINICAL AND DIDACTIC, 

upper surface of the tongue, upon its fraenum, on the frsenum of 
the lower lip, on the gums, the cheeks, 4 or the roof of the mouth, 
and even in the throat and fauces. They are painful in propor- 
tion to the extent of the raw surface which is exposed, and to the 
depth of the ulceration. In exceptional instances the,->e ulcera- 
tions have dipped down to the bone beneath. 

It is not unusual for these characteristic lesions to disappear 
suddenly, leaving the patient in apparent health. After a brief 

interval, however, they reappear, and may thus 
lesion" 010 " 5 nature ° f the keep coming and going for weeks, or even for 

months. In the most serious cases this sudden 
metastasis increases the danger, by implicating other and more 
vital organs. 

Symptoms of gastric or alimentary disorder almost alwa} T s 
accompany those peculiar to this variety of sore-mouth. They 

may precede, follow or alternate with the buccal 

Incidental gastric disorder. 

symptoms, but are rarely altogether absent. I 
have seldom treated a case of this form of stomatitis, during 
either pregnancy or lactation, which was not accompanied by 
epigastric uneasiness, anorexia, or pyrosis. Instances in which 
this disease runs its course without a more or less decided 
implication of the stomach and bowels are believed to be very 
rare. 

In this respect the stomatitis materna resembles the aphthae of 
infants which, as you are aware, is almost invariably accom- 
panied by intestinal derangement, more especially indigestion 
and diarrhoea. 

The concurrent digestive disorder in this variety of sore-mouth 
has been attributed to various causes, among which are the imper- 
fect mastication of food ; an improper and 
dem a n U gJme°nt. the dIgestive unwholesome diet ; the actual transfer, or the 
continuation, of the local lesion to the gastric 
and enteric mucous membrane ; to a depraved nutrition from other 
causes, and to glandular disease either in the intestine or the 
mesentery, or both. 

Among the numerous contingencies of pregnancy and parturi- 
^. , tion there are few which are more troublesome 

Diarrhoea. 

than an inveterate diarrhoea. This is especially 
true in patients of a scrofulous or tuberculous diathesis. And it 



ON THE DISEASES OF WOMEN. 215 

is this class of subjects which is most liable to be seized with it 
after labor. When complicated with stomatitis the diarrhoea may 
either anticipate or follow the symptoms already enumerated. 
More frequently, however, it alternates with them — a fact which 
implies a metastasis of the peculiar disorder from the oral to the 
intestinal mucous membrane. 

Disordered digestion and assimilation are, therefore, almost cer- 
tain to exist in well-marked cases of stomatitis materna. Not 
unfrequently they are the source of well-grounded apprehension, 
and, if ever so slight, they will occasion you no little anxiety. 
You should bear in mind, however, that the coincident diarrhoea 
is but a symptom, and that its essential pathology is the same as 
that of the buccal erythema, eruption, and ulceration. 

Beside local suffering in the mouth, the patient may complain 
also of a troublesome strangury, with smarting or scalding sensa- 
tions during, or immediately after urinating. 
toms nal and vesical symp " Occasionally these symptoms precede those 
already enumerated. Sooner or later they are 
almost certain to be present, and when they are not mentioned 
voluntarily, you will learn, upon inquiry, that they really exist. 

The urine is most commonly acid in its reaction — a symptom 
reputed by some authorities to be pathognomonic of this variety 
of stomatitis. Its specific gravity will vary from 1024 to 1030. 

For the most part, the general symptoms are such as imply a 
debility which may be extreme. If the disease has existed for any 
considerable time, the patient is usually anaemic. 
She is pallid and exhausted, and the face ap- 
pears puffy and bloated. Her complexion is less waxy and clear 
than in chlorosis, but has a sallow and cadaverous shade in it, 
which is not common in other diseases. 

These symptoms are likely to be accompanied by an irritative 
fever which may remit regularly and finally develop into a real 
liectic. It is said that primiparse are more liable than multiparas 
co this form of stomatitis. With certain women it appears to be 
constitutional, and always recurs during pregnancy or lying-in. 
± he milk furnished by the breast may be either deficient or ex- 
cessive in quantity. Not unfrequently it is of such quality as to 
poison the child and render it sickly and short-lived. 

Wherever it may be located, authorities are not agreed as to 



216 LECTURES, CLINICAL AND DIDACTIC, 

whether the anaemia in this disease is the cause or the conse- 
quence of the local inflammation and ulcera- 
tion. The simple fact that it is limited to the 
periods of gestation and lactation, when the blood is being drained 
of certain elements for the support of the young, and that, as a 
rule, it ceases as soon as the child is born, or weaned, suggests 
that the anaemia must have preceded the local lesion. And such 
is the case. The woman may have been in ill-health for a con- 
siderable time before the sore mouth commenced. This primary 
impairment of the quality of the blood explains the greater lia- 
bility of young, scrofulous, weakly and sickly persons, as well as 
of those whose systems have been reduced by frequent child- 
bearing, to the disease under consideration. It also affords a 
reason for the more general prevalence and malignity of this dis- 
ease in miasmatic districts, and in those localities and seasons in 
which there is a scarcity of fruits and vegetables, and where, as a 
consequence, the stomatitis degenerates into a species of " land 
scurvy.' 1 

We can not otherwise explain the migratory character of the 
disease, its tendency to invade the pharynx, the oesophagus, and 
the gastro-intestinal tract, the respiratory apparatus, the nasal 
passage, the Eustachian tube, and even the genito-urinary outlet. 
In the order of its occurrence therefore, the anaemia is doubtless 
the first visible sign of the impaired nutrition upon which the 
stomatitis really depends, and without which it can not exist. 

This form of stomatitis may commence in the early, the middle, 

or the latter months of gestation, and persist to term or even later. 

Or it may date from delivery, from the first 

Onset of the disease. _ . 

month of nursing, or perhaps later and continue 
for an indefinite period. In very rare cases it exists in the form 
of pruritus of the vulva during pregnancy, and after child-birth 
develops into stomatitis proper. 

Diagnosis. — The diagnosis is not difficult. The sex of the 
subject and the peculiar circumstances in which she is found — 
either pregnant, or in one or another of the stages of recovery 
from her confinement, — with the local symptoms already detailed, 

will enable vou to diagnosticate it readilv- It 

It may be latent. J ° J 

is only when this disease is obscure and runs a 
latent course, being limited to the gastric, alimentary, or urinary 



ON THE DISEASES OF WOMEN. 217 

mucous membranes, that you would be likely to overlook it, or 
fail to distinguish it from other similar and serious affections. 

Prognosis. — The prognosis will vary with the original strength 
of the patient's constitution ; her age, habits and surroundings ; 
the co-existence of tuberculosis of the lungs, or 
of the mesenteric glands; the period of the 
commencement, and the duration of the disorder ; the type and 
persistence of the accompanying fever ; the seat, nature and ex- 
tent of the local lesion ; the anaemia and the emaciation. 

If, prior to becoming pregnant, the patient was robust and 
healthy, and had no cachexy, either hereditary or acquired, the 
probabilities are in favor of her recovery. This result is the more 
certain if she is young, of good habits, and lives in a healthy 
neighborhood. A tendency to phthisis in any of its forms is 
always a grave complication. If the stomatitis commences in the 
early months of gestation, it can seldom be cured before delivery, 
and other things equal, the longer its duration prior to labor the 
greater the danger. In rare cases it results in abortion, after 
which it ceases spontaneously. 

If the accompanying fever is either typhoid or hectic in its type 
and character, you will need to qualify your prognosis. And so 
also if the disease has become chronic, with deep-seated ulcera- 
tion in the intestines, the stomach, or the larynx and trachea. 
The occurrence of passive, or repeated, or excessive haemorrhage 
from the mucous surface implies great danger. The more the 
blood is impoverished and vitiated, and the greater the emaciation 
and the muscular and nervous exhaustion, the fewer the chances 
of a speedy and certain recovery. It is sometimes quite impos- 
sible to eradicate this disease in the case of women who have had 
it in several successive pregnancies. Although recovery fre- 
quently follows the weaning of the child, yet even this expedient 
sometimes fails. The danger is increased by excessive or pro- 
longed medication. 

Treatment. — The first thing to be done is to select a suitable 

diet. This consists of a proper admixture of vegetable and 

animal food, for vou will observe that in many 

The diet. . ! -,.-,-, i - i 

cases the patient has lived almost exclusively 
upon meat. In frontier settlements, people sometimes eat little 
or nothing excepting bread and bacon. In such communities the 



218 LECTURES, CLINICAL AND DIDACTIC, 

women suffer from an aggravated form of the nursing sore-mouth, 
which is closely allied to scorbutus, and which may sometimes be 
cured by merely regulating the diet. Even in towns ana cities 
similar cases are not infrequent. 

The taking of solids is usually so painful that food must be 
given either in the semi-solid or fluid form. If, however, she can 
eat it, rare roast beef or mutton, or broiled meats which are juicy 
and nutritious, may be prescribed with good effect. She may 
also have milk, eggs, oysters, game, plain custards, animal jellies, 
cracked wheat, oatmeal, or, if she prefers, a little codfish with 
cream. Salt food may be permitted as an appetizer, but should 
be used sparingly. Potatoes, carrots, tomatoes, baked apples, 
and other fruits and vegetables, if fresh and fully ripe, are not 
only permissible but indispensable. Cures have been effected by 
allowing the patient to drink freely of butter-milk. 

Other acidulated drinks are almost specific. Lemonade, orange- 
ade, and jelly-water, are most available. They may be taken 
either warm or cold, as the patient prefers, and 

Acidulated drinks. • t -, • /» . -i. 

are not contra-mdicated m most cases of indi- 
gestion and diarrhoea. Nor will they antidote the proper reme- 
dies. The best criterion, in their selection, is to consult the 

patient's preference, or craving, if she has any. 

Rule for choosing them. . ^ 

lhe same is true with respect to the diet. As 
a rule, you may let her have whatever she longs for in the way of 
food or drink, providing it is not wholly indigestible or absolutely 
poisonous. The malt liquors and cod-liver oil have also been 
added to the bill of fare. 

The expedients devised to check this disease, and to hold it in 
abeyance, and which are sometimes successful, 
thfs x d p i^ase. ts for arresting are the induction of premature labor, the wean- 
ing of the child, and a change of climate. 
The induction of premature labor is justifiable only in those 
extreme cases of stomatitis in which it is morally certain that the 
patient must die unless pregnancy is terminated 

Premature labor. ^ ± o J 

and the womb emptied of its contents. Fortu- 
nately such an extremity is almost never reached prior to the 
seventh month of pregnancy, after which the child is viable. In 
a resort to this expedient under such circumstances there is no 
warrant for the performance of criminal abortion, which implies 
and includes the intentional sacrifice of the foetus. 



ON THE DISEASES OF WOMEN. 219 

Because taking the child from the breast of the mother who 

has stomatitis will sometimes be of immediate and lasting benefit 

to her, physicians have inferred that weaning 

Weaning the child. -, r™ . 

was the best remedy. The custom with some 
is to prescribe it indiscriminately. So soon as they discover the 
slightest inflammation and exfoliation of the oral mucous mem- 
brane, further nursing is prohibited. But weaning will not always 
mitigate or arrest this disease. Nor is it necessary to resort to 
this expedient in a majority of the cases that come under our care. 
Unless it is manifest that the mother is pretty nearly bankrupt in 
strength and nutritive resource, that she is drawing her life away 
to keep her child alive, that she is so ansemic and emaciated as to 
be totally unfit both on her own and the infant's account to nurse 
it any longer, we prefer not to interrupt this very important func- 
tion. 

A change of climate, especially if the patient leaves a mias- 
matic district, will sometimes cause the symptoms of this disease 
to disappear promptly and permanently. In 

Change of climate. A . i t r r -i ^ 

exceptional cases a removal oi a lew miles only 
will work almost as marked a change in her feelings as it does in 
certain cases of asthma and of intermittent fever. This expe- 
dient is particularly applicable if the stomatitis is complicated 
with chronic bowel affections. Railway travel is indicated if 
there is an inveterate diarrhoea, and residence in an equable cli- 
mate for those mothers who are consumptive. Hysterical sub- 
jects, with the nursing sore-mouth, may sometimes be sent away 
from home with the greatest relief to themselves and all con- 
cerned. 

The medical treatment of this disorder is constitutional and 

local. Of internal remedies, the various acids are in the best 

repute. The nitric acid has been given in the 

The medical treatment. . . . , , 

lower and higher potencies, under almost every 
variety of indications, and often empirically, with good results. 
The sulphuric and muriatic acids are equally useful. I remember 
a case in which two prominent physicians had treated a lady for 
stomatitis materna for two whole months. She 
grew worse and worse. Finally they told her 
that she must wean her infant, and that after doing so she could 
not recover her health under at least one year. I made her but 



220 LECTURES, CLINICAL AND DIDACTIC, 

three visits, ordered a nutritious diet, and prescribed sulphuric 
acid in the third decimal dilution to be taken 
four times daily. She continued the remedy 
for the space of a fortnight. A radical cure followed, without 
weaning the child, or the employment of any local application 
whatever. My practice is to put twenty-five drops of the second 
or third attenuation of either of these acids in half a glass of 
water, of which two teaspoonfuls are to be taken once in from 
three to six hours. 

Arsenicum is generally suitable for cases of this form of stoma- 
titis which are to be met with in malarious districts. If there is 
burning in the mouth, with frequent desire for 

Arsenicum album. . _ . 

cold drinks ; 11 the water which the patient 
drinks habitually is stagnant or impregnated with decomposing^ 
matter of various kinds ; if there is great prostration of strength, 
anorexia, with chronic disorder of digestion and painless diarrhoea ; 
if the system has been poisoned with quinine in large doses, or if 
the accompanying symptoms are analogous to those of typhoid 
fever, it may prove of excellent service. The same indications 
will call for natrum muriaticum. Dr. Murch was in the habit in 
these cases of alternating the arsenicum with small doses of Bel- 
locq's charcoal. If the disease is complicated with glandular dis- 
ease of a scrofulous or syphilitic character, the arsenicum jodatum 
might be preferable. Dr. D. T. Brown* has witnessed the best 
effects from preceding the employment of arsenicum with a few 
doses of carbo vegetabilis. Dr. W. C. Barker extols the use of 
u arsenicum 6th in alternation with sulphur 6th, repeated once in 
four hours, in those cases of nursing sore-mouth which are char- 
acterized by a very slight and almost imperceptible odor of the 
breath, with considerable prostration of the general strength/" 
Dr. I. S. P. Lord vouches for the superior efficacy of arsenicum 
and natrum muriaticum in the 30th, in preference to other attenu- 
ations. 

The form of this disease to which mercurius is best adapted is 
that in which the ulceration of the tissues is very marked. The 

ulcers are corroding", the breath offensive, the 

Mercurius. ° 

secretion of saliva profuse, in short, the symp- 
toms are those of the stomatitis ulcerosa of the old writers. If 

* Vide Transactions of American Institute of Horn., for i860, p. 78. 



ON THE DISEASES OF WOMEN. 221 

there is no syphilitic taint, the mercurius corrosivus is preferable, 
otherwise the mercurius jodatus, or even the mercurius solubilis, 
may be selected. 

Where disorders of digestion in pregnant or lying-in women 

are due to a latent stomatitis, and particularly in patients who are 

predisposed to scrofula or phthisis, the calcarea 

Calcarea carbonica. . . 

carbonica may be or excellent service, ine 
symptoms which indicate it are dryness of the mouth and tongue, 
with a sense of roughness and stinging ; a dry, bitter, sour, or 
metallic taste ; great aversion to boiled food and to meats in par- 
ticular ; inclination to salt diet, or to such indigestible articles as 
pickles, dirt, chalk, slate-pencils, etc. ; nausea, with acid eructa- 
tions ; vomiting of ingesta ; profuse colliquative diarrhoea, with 
undigested stools ; a sudden metastasis of the eruption from the 
mouth to the alimentary mucous membrane ; and acidity of the 
urine, with burning in the urethra during micturition. There are 
some examples of this disease which it would be very difficult, if 
not indeed impossible, to cure without this remedy. 

Dr. Helmuth reports* that ammonium carbonicum cured a case 
of long standing in which there was great prostration, hollow 

cough, and burning in the tongue — the whole 

Ammonium carb. , , • , i • r»i-ii m • i i 

buccal cavity being filled with vesicles and 
ulcerated depressions, and the tongue swollen, stiff, and very sen- 
sitive to cold air and drinks. 

He also cites the case of a young lady cured by the use of 
baryta carbonica, for which remedy the chief 
indication was the absolute and complete 
anorexia. 

" In an emaciated female who had suffered severely from the 
disease, and had been troubled for a long period 

Natrum muriaticum. . , . . -. 

with ague, natrum muriaticum and arsenicum, 
in repeated doses of the 6th attenuation, effected a cure in twenty- 
one days." 

In the report to the American Institute, from which I have 
already quoted, my friend, Dr. N. F. Prentice, says : " Formerly 

I had a great deal of trouble in the treatment 

Veronica beccabunga. . 

of this disease, and 01 sore mouth in children, 
but during the last three or four years I have used the veronica 

*U. S. Journal of Horn., Vol. I, p. 413. 



222 LECTURES, CLINICAL AND DIDACTIC, 

(empirically it is true, for I have but a very few provings of it,) 
almost exclusively, and with universal success. I have been in 
the habit of giving it internally in the first decimal attenuation, 
and of applying it locally to the mouth in the proportion of ten 
to thirty drops in two fluid-ounces of soft water. When they are 
indicated, I use other remedies in alternation with veronica." 

Dr. J. Davies has succeeded in some obstinate cases by the 

application of a trituration of the rhus toxicodendron, and an 

internal use of the attenuations of the same 

Rhus toxicodendron. . . 

remedy. He triturates the berries of this plant 
with sac char um lactis, in the proportion of one berry to ten grains 
of the sugar, and applies the powder, moistened, through the 
medium of a thin linen cloth. 

Other remedies which are sometimes serviceable are belladonna, 
causticum, china, nux vomica, sulphur, hepar sulphuris, ferrum 
and staphisagria. 

Topical applications of various kinds are grateful and beneficiaL 
The most common and harmless consist of lotions, washes and gar- 
gles, composed of borax, or borax and honey, 

The local treatment. . _ 

sage and borax, a mixture ot equal parts or 
borax and sugar in a pulverized state, tincture of myrrh, an infu- 
sion of the golden seal, or of cayenne pepper, butternut oil, or 
glycerine. Some physicians recommend the chlorate of potassa 
to be dissolved in, glycerine and applied locally. Others prefer a 
very weak solution of the carbolic acid. And yet others are in 
the habit of prescribing the topical use of hydrastin in water, or 
glycerine, or both. In cases where the buccal and faucial mucous 
membrane is badly ulcerated and the breath is fetid and offensive* 
a drachm of the mother tincture of baptisia may be added to four 
fluid-ounces of water and applied locally. Or Bretonneau's mixt- 
ure of one part of hydrochloric acid and three parts of honey may 
be used instead. Dr. Barker has the greatest confidence in fre- 
quent rinsings of the mouth with simple cold water. There are 
those who, in exceptional cases, think it necessary to touch the 
ulcers with a pencil of the nitrate of silver. I prefer calendula, 
or hydrastin. Tannin and other astringents are harsh and revul- 
sive, and may do more harm than good. 



ON THE DISEASES OF WOMEN. 223 



LECTURE XIII 



PUERPERAL CONVULSIONS. 



Gentlemen : 

I propose to-day to offer you some remarks on puerperal con- 
vulsions. I will first read you the history of a case which has 
been kindly furnished by my friend, Dr. L. H. Holbrook of this 
city: 

Case. — Mrs. K , primipara, aged 26 years, of leuco-phleg- 

matic temperament ; seven months advanced in pregnancy ; had 
been troubled with pains in the left hip and leg, with some en- 
largement of the limb ; pains were relieved by rhus tox. 3rd, and 
Pulsatilla 3rd, and still more decidedly by rhus tox. 200th. 

Jan. 6th. — She ate hickory nuts at an evening entertainment. 

Jan. 7th. — Ate baked beans for dinner, and quite freely of fried 
ham for supper. 

Jan. 8th. — At 12:30 A. M., was attacked with pain in the lower 
part of abdomen, more like colic than labor pains. At 5 A. M., I 
was called and found that she had had two movements of the 
bowels, and had twice vomited bilious matter. In view of her 
errors in diet I gave pulsatilla 3rd, which was followed by slight 
improvement. I left her at 7 A. M., on chamomilla 3rd and nux 
vomica 3rd, in solution, a teaspoonful to be taken every half hour 
alternately. 

II A. m. The pain is lessened, but she is very much nauseated. 
Gave a single dose of ipecac, 3rd, and continued former prescrip- 
tion. At 5 P. m., administered an injection per anum, containing 
one drachm of opium 1st. At 6 P. M., pain nearly all gone ; vom- 
iting still troublesome. At this hour left her, feeling confident 
that she would recover without implication of the uterus. About 
7 P. m., she said that she felt strangely, and was immediately con- 
vulsed. Digital examination was now made. Found the head of 
'the child presenting at the superior strait ; the os uteri not dilated 
or tense, but soft and patulous ; no expulsive pains. Gave of 
atropine, 2nd decimal, in water, a teaspoonful every half hour. 
This was followed by apparent benefit, as the intervals between 
the spasms were lengthened. The paroxysm commenced by first 



224 LECTUBES, CLINICAL AND DIDACTIC, 

the eyes, then the head turning towards the left side ; this was 
followed by muscular tremor and a jerking motion of all the limbs. 
She then subsided into a state of stupor, with stertorous breathing, 
until the next paroxysm came on, when the same symptoms would 
be repeated. 

Jan. 9th. — 5 A. M. Prof. R. Ludlam was called in council. A 
careful examination, per vaginam, disclosed the os uteri in the 
same condition as already described. There was an entire absence 
of uterine contraction. We decided that operative interference 
was contra-indicated. Gave ignatia every half hour. She also 
received an enema of sulphuric ether and milk. 

11 A. m. The interval between the fits is lengthened, but it is 
characterized by great restlessness and constant motion of all the 
limbs. Has passed urine involuntarily several times. Foetal heart- 
sounds heard distinctly. At 3 p. M. the bag of waters ruptured 
suddenly, and upon examination found the head pressing hard 
upon the perineum. At 4 P. M. she was delivered, during a con- 
vulsion, of a dead foetus. After delivery only two convulsions 
occurred, but the jactitation and constant motion of the limbs 
continued. 

8 P. M. At the suggestion of my friend, Dr. Kellogg, camphor 
was given for the restlessness. I decided upon its use, although 
it had been freely administered by olfaction during the first spasm, 
without any positive benefit. Five drops of the tincture of cam- 
phor were dropped upon a little sugar, then dissolved in half a 
glass of water, and a teaspoonful given every half hour. Marked 
improvement soon followed. Gradually the motion lessened, and 
at 12 m. she was quiet and sleeping. 

Jan. 10th. — 9 A. m. My patient begins to manifest signs of 
returning consciousness. Camphor was used continually through 
the day, with intercurrent remedies. 

Jan. 11. — Has rested well during the night. Partial recogni- 
tion of friends ; answers questions correctly, but is oblivious of 
what has passed. Tongue and lips very dry, red and swollen , 
notwithstanding our efforts to protect them, she had injured them 
somewhat during the spasms. Continue the camphor ; mouth 
moistened with slipper}^ elm water ; barley water for drink. 

Jan. 12th. — Was called at 1 A. M. ; patient possessed with the 
idea that she will not get well, and talks about dying. Discontin- 
ued camphor and gave aconite 3rd every two hours. At 4 P. M., 
marked improvement of mental faculties, although her peculiar 
fancy is still troublesome. Has passed urine copiously, which 
deposits a brick dust sediment. The past is yet a blank to her ; 
does not remember that she has been pregnant even, but thinks 
another, a friend of hers, was in that condition. 

Jan. 13th. — The mind much clearer; has concluded to get 



OX THE DISEASES OF WOMEN. 225 

well ; remembers the marriage of her sister, which occurred a few 
months ago ; has troublesome haemorrhoids ; never had them 
before. 

Jan. 14th. — Sleeps well; improvement gradual and constant; 
she begins to ask questions about her illness. 

Jan. 20th. — Mind quite clear ; inquired about her baby, and 
when informed of her loss was affected to tears. Ignatia3rd every 
three hours. 

Jan. 22d. — Continued improvement ; appetite good ; she sat 
up three hours yesterday; has some headache in consequence of 
seeing too much company. There has been no secretion of milk. 

Of all the contingencies of parturition perhaps none is so alarm- 
ing and serious as puerperal convulsions. Fortunately, however, 

they are among the rarest complications and 

sequelse of labor. Cazeaux gives a table of 
38,306 deliveries by English obstetricians, in which only 79, or 
one in 485, had convulsions. In a thousand labors superintended 
by him at La Clinique, Velpeau did not observe a single case. In 
10,387 cases of labor, Dr. Joseph Clarke met with 19 cases of 
convulsions ; Dr. F. H. Ramsbotham, in 68,435 deliveries, had 67 
cases, or less than one in a thousand ; Dr. Collins in 16,414 labors, 
encountered 30 cases of convulsions. As with preternatural labors 
in general, their very infrequency affords a powerful argument for 
the careful study of the pathology and treatment of puerperal 
convulsions. 

These convulsions have been divided by obstetrical authorities 
into the epileptic, the hysterical, and the apoplectic. There is 

good reason, however, for considering the true 
<:ations eties and comp11 " puerperal eclampsia' an affection which is quite 

distinct from, although it is not unfrequently 
complicated with, epilepsy, hysteria, apoplexy, and sometimes with 
chorea, catalepsy and tetanus. 

Only a very small proportion of women who have puerperal 
convulsions are predisposed to, or have ever had epileps}'. In 

those who have been subject to epilepsy prior to 
subjecS pti ° n ° f epileptic conception, the pregnant state is more likely to 

arrest than to increase the frequency and sever- 
ity of the paroxysms. Dr. Tyler Smith reports that in 51 preg- 
nancies occurring in 15 epileptic subjects, only two had puerperal 
convulsions, while only one of all Dr. Churchill's patients afflicted 
15 



226 LECTURES, CLINICAL AND DIDACTIC, 

with epilepsy had them. The manner of approach of the fit, the 
absence of the " aura epileptica," its frequent recurrence, its vari- 
ous causes, its relation to the uterine contractions and sympathies, 
and its clinical history throughout, prove that the epileptiform 
symptoms present in the convulsions of child-bed are mere contin- 
gencies thereof, which may modify, but are not essential to, and do 
not explain the real nature of the disease. 

The hysterical convulsions are more liable to occur in the earlier 

than during the later months of pregnancy. They scarcely deserve 

the title of convulsions, and their consequences 

Hysterical convulsions. . 

are not often directly serious. .Patients of a 
well-marked hysterical constitution are perhaps more strongly pre- 
disposed than others to puerperal convulsions. The local and 
limited spasmodic phenomena that sometimes accompany or follow 
labor in nervous and highly excitable women, are purely hysteri- 
cal. In brief, hysteria, like apoplexy, catalepsy or tetanus, " may 
occur in the puerperal state, either as the principal disease, or as a 
termination or complication of eclampsia. " 

Clinical History. — The attack may set in at any period of preg- 
nancy, during labor, immediately subsequent to the delivery of 

the child and the secundines, or some hours, 

Date of commencement. . . 

days, or even weeks after parturition. Of 59 
cases reported by Ramsbotham, 17 commenced before labor, 28 
during its progress, and 14 after its termination. In the experience 
of Braun and Weiger 24 per cent, set in before the commence- 
ment of uterine pains, 54 per cent, during labor, and 24 per cent, 
after the birth of the child. 

Depaul cites a case of puerperal convulsions which occurred in 
the fourth month of gestation ; Perfect two cases before quicken- 
ing ; Meigs one at five months ; Empson one at 

During gestation. it t» t 

the tenth day after delivery ; Ramsbotham one 
at the sixteenth day, and Sever, Hardy, Braun, Simpson and 
Devilliers report examples commencing as late as the sixth week. 
It is believed that convulsions incident to the pregnant state are 
more likely to occur at and after, than before the seventh month. 
When they take place during labor, the convulsions are apt to 

terminate with delivery. In some cases they 

Influence of delivery. . « . . 

continue for a period but recur at longer inter- 
vals, after the uterus has been emptied. More rarely, however 



ON THE DISEASES OF WOMEN. 227 

they do not seem changed either in degree or frequency by the 
conclusion of labor. Braun says that the fits completely cease 
after the evacuation of the womb in 37 per cent., become weaker 
in 31 per cent., and in only 32 per cent, continue of the same 
severity. 

Convulsions are most likely to commence when, having escaped 

the os uteri, the presenting part occupies the vagina, lies upon 

the perineum, or is about to protrude at the 

Coming on of the fit. . , . 

vulva, ihere are, however, exceptions to this 
rule, in which rigidity of the anterior lip of the os may prevent 
the passage of the head, and convulsions begin before it has 
emerged from the uterus. A highly irritable and sensitive con- 
dition of the soft parts renders the more nervous and delicate 
women liable to attacks of convulsions during labor. This state 
being always more marked in those who are in labor for the first 
time, it follows that such patients are more subject to convulsions 
than those who have already borne children. More than two- 
thirds of all the cases of puerperal eclampsia occur in primiparse. 
Of thirty cases of this disease noted by Dr. Collins, 29 occurred 
in women for the first time in child-bed ; and of those reported 
by Dr. Merriman the same was true of 36 out of 48. 

In the great majority of examples of this disorder, excepting 

of course where there are twins, the child is of the male sex. Of 

28 cases cited by Dr. Collins, in 17 the offspring 

Most frequent in birth of i n i •• in _e 

male children and in head was a male, bo also, m nearly all cases of 

presentations. 

puerperal eclampsia we have head presentations. 
In the Dublin Lying-in Hospital only a single case of convulsions 
coincident with malposition occurred in 48,397 labors. The only 
variety of preternatural labor, due to false position or presenta- 
tion, to which convulsions are incident, is placenta prsevia. 

It is not certain that because a woman has had puerperal con- 
vulsions in her first labor, she will therefore have them subse- 
quently. Nor will one attack exempt her 
subie^lXpr^ entirely. There are exceptional instances in 

which the pregnant, parturient, and lying-in 
states may always be accompanied by them. An example of this 
kind is reported in the Proceedings of the London Obstetrical 
Society (Vol. I, p. 108), in which abortion with convulsions occur- 
red six times successively in the same patient. Lumpe relates a 



228 LECTURES, CLINICAL AND DIDACTIC, 

case in which convulsions were experienced in the first, second, 
and fifth deliveries ; Dr. I. S. P. Lord one in which a woman 
had convulsions in three, and Litzmann another in which a like 
result followed in nine successive pregnancies. 

The fit may set in abruptly, or there may be premonitory symp- 
toms which vary in individual cases. Excessive restlessness, 
irritability, rigors, flushed face, headache, mal- 

Premonitory symptoms. . -■-,.. . «,.. . ., 

aise, delirium, imperfect vision, amaurosis with 
dilated pupils and staring expression, rumbling noises in the ears, 
hypochondriasis, vomiting, a slow pulse which rises very quickly 
when the paroxysm has commenced, and twitching of the muscles 
of the face and extremities, are among the prodromi of this 
dangerous affection. An intent -look of the patient at the ceiling 
or corner of the room upwards, and the following as of an object 
by the eye is a threatening symptom. 

In the majority of cases, however, there will have been obser- 
ved by the modern and more intelligent physician, a tendency to 
anasarcous swellings in various parts of the 
sySp°tom. a precursory body. This symptom, first observed by Hamil- 
ton and Demanet more than sixty years ago, 
may sometimes be remarked many weeks before " term," and, 
although it is not always followed by convulsions, is really to be 
interpreted as a foretoken of convulsibility. This dropsical puffi- 
ness may be limited to the upper extremities and the face, but is 
more frequently seated in the lower limbs, the ankles, the feet, 
and even in the labia majora. In exceptional cases, it nearly 
or quite disappears towards the end of gestation, so that its sig- 
nificance is sometimes over-looked, by one who sees his patient 
for the first time during the parturient act. 

As the fit approaches, the eyelids wink incessantly, the eyes 

are rolled upwards and fixed, the pupils dilated, the features are 

changed, the facial muscles jerk and twitch 

The convulsive stage. ° _ p . ._ 

spasmodically, the angle of the mouth is drawn 
to the side corresponding with the unnatural position of the eye- 
balls, the head rotates slowly in the same direction, and the 
muscles of the neck, arms, trunk, and legs are successively con- 
vulsed. The throat, the larynx, the pharynx, the diaphragm, and 
other respiratory muscles are also seized, and respiration be- 
comes interrupted, irregular, tumultuous, or altogether suspended. 



ON THE DISEASES OF '.WOMEN. 229 

There is stridulous expiration with hasty inspiration. In conse- 
quence of these latter spasms there is asphyxia, with discoloration 
of the surface and turgidity of the skin, neck, features, eyes, and 
tongue. The anal and vesical sphincters may be affected, and 
involuntary passages of fasces and urine follow. In some cases 
the uterus is suddenly emptied of its contents. The hands are 
clenched, and occasionally the arms thrown wildly about. I have 
read of an example in which the head of the humerus was luxat- 
ed from this cause. The muscles of the jaw are spasmodically 
contracted and the teeth closed firmly and suddenly, in conse- 
quence of which the tongue, mouth, and cheeks may be badly 
bitten. The salivary glands secrete an unusual quantity of saliva, 
which is discolored by blood from the wound caused by the sudden 
closure of the jaws. M. Finney cites a case in which the lower 
jaw was dislocated during a convulsion. Denman observed that 
the forcible expiration of the breath through the teeth, which are 
firmly set, produces a hissing sound that is quite pathognomonic. 
Sometimes this is the first symptom noted in an attack. . 

There are several items of interest connected with the natural 

history of convulsions. I can only name a few of them in this 

connection. The progress of the spasmodic 

Peculiarities of. _ , 

action trom above downwards is peculiar ana 
significant. In all the cases treated by me, the head has been 
turned to the right side. Meigs has remarked that the spasms 
affect first the extensor and then the flexor muscles of the extremi- 
ties, and that this is followed by a rigidity of both. 

Although, if long continued or frequently repeated, the inter- 
ruption of respiration and consequent asphyxia may result in fatal 
effusion into the cerebro-spinal cavity, yet the 
discoloration of the blood and complete insen- 
sibility induced thereby are to be regarded as a species of critical 
anaesthesia, which is designed to put an end to the paroxysms. 
When the fit is over the patient may sleep quietly, or it may be 
followed by stertorous breathing. Where the convulsions have 
not persisted for a considerable time, and are neither very frequent 
nor severe, there is a gradual return of consciousness. Otherwise 
the patient becomes comatose and finally quite insensible to 
external impressions. In plethoric subjects who are predisposed 
to apoplexy, this symptom is observed at an earlier period of the 



230 LECTURES, CLINICAL AND DIDACTIC, 

disease, and is of much more serious import. The more rapid the 
paroxysms, if truly eclamptic, the more sudden and complete the 
loss of consciousness. 

Litzmann has remarked that at the onset of the convulsion 

the pulse is slow and then rises very quickly to 120 or 150 in 

the minute. It also becomes smaller and 

The pulse. . . 

quicker as the intervals between the con- 
vulsions are lessened. 

The duration of the fit, of which I have given but a brief out- 
line, varies from one to five or more minutes. If they take place 
during labor, they are likely to recur with the 
of^hrplmxy"! repetkion regularity of the uterine contractions. Some- 
times, although rarely, the convulsions com- 
mence before the pains. Wegscheider reports a case in which the 
fits began forty-eight hours in advance of labor. In post-partum 
convulsions, even in primiparse, I have observed that they usuallj- 
return with each " after-pain," and, if all goes on well, they 
diminish in frequency as these tormenting sequelae of labor dis- 
appear. They may continue, at longer or shorter intervals, for 
from a few hours to several days. The patient may have but one 
fit, or she may survive, or succumb to thirty, forty, or even a 
hundred of them. As a rule, if the mother has more than three 
or four severe convulsions prior to delivery, the child or children 
will be still-born. Where they occur subsequently to labor, the 
milk and lochia are suppressed. 

Etiology. — The causes are predisposing and exciting. Among 

the former are the hysterical constitution, and all those influences 

and habits of life which develop it, whether 

Predisposing causes. _. . .. .. 

directly or indirectly. A tendency to apoplexy, 
epilepsy, anaemia, or renal disease, also predisposes to an attack 
of puerperal eclampsia. The same is true of an hereditary lia- 
bility to spasmodic affections generally. Puerperal convulsions 
are more frequently met with in cities and larger towns than in 
rural districts. 

The exciting causes are numerous and varied. Eminent 
authorities have observed that convulsions in child-bed are in a 

sense gregarious. In 2,000 deliveries, of which 

Exciting causes. t -ittt^. 

Cazeaux had charge at the Hotel Dieu, and the 
College de la Faculte there were but three cases of convulsions, 



OX THE DISEASES OF WOMEN. 231 

while iii his service at La Clinique during only four months there 
were seven cases of this kind. Ramsbotham remarked the same 
fact, and also the occurrence of several cases during warm 
weather, when the clouds were charged with electric fluid. In 
private practice I once had two patients, who were in no wise 
related or acquainted, seized with puerperal eclampsia during 
the same week — a coincidence by no means grateful or desir- 
able. 

Certain emotional states may predispose to, or precipitate an 
attack. In one of my patients, a primipara, the post-partum 
seizure was induced by mental agitation of the mother, lest scan- 
dal might come of the fact that her child was born at somewhat 
less than nine months after marriage. Fear and dread of the fit 
is a powerful exciting cause. In rare cases, where the parts are 
in.a state of hyperesthesia, or the patient is more than ordinarily 
averse to the necessary examination, the " touch " may bring on 
the first paroxysm. Excess of joy and demonstration over the 
birth of the child, especially if the labor has been brief and rapid, 
fright and anger, shame, misery, disgust, or the meeting between 
husband and wife during or subsequent to delivery, may have the 
same effect. The eating of improper food in the later months of 
gestation has been known to induce convulsions. Mr. Owen 
Davis reports a case of this kind occurring at the eighth month, 
that was caused by eating mussels. In advanced pregnancy shell- 
fish are, for this reason, objectionable articles of diet. In Dr. 
Holbrook's case the improper diet of the patient probably caused 
the convulsions. Great exhaustion from excess of fatigue, pro- 
tracted labor, or profuse haemorrhage, will, in some cases, occasion 
puerperal convulsions. 

But the causes I have enumerated are not in themselves suffi- 
cient in all cases to account for the production of this frightful 
disease. Concerning the conditions and circumstances that are 
necessary and adequate to this result, authorities are not agreed. 
There are three several theories on this subject, which, for the 
sake of perspicuity, we shall style (1) the mechanical, (2) the 
nervous, and (3) the toxemic. 

The mechanical hypothesis attributes the symptoms of puerperal 
•eclampsia to pressure of the gravid uterus upon the larger ves- 
sels, and consequent derangement of the circulation both in the 



232 LECTURES, CLINICAL AND DIDACTIC, 

abdomen, the lower limbs, and also in the head and upper ex- 
tremities. Not only is the proper distribution 
uT^eSrconvufsion?' 11 of 0I> tne Wood directly interfered with by this 
means, but its quality is impaired, and it be- 
comes less nourishing and more noxious to all the tissues with 
which it is brought into contact. The nerve-centers being espe- 
cially susceptible, are the more likely to suffer from this cause, 
and nervous and convulsive phenomena are the natural and 
necessary consequences. This view is supported by the fact that 
convulsions occur more frequently in those whose abdominal 
parietes and tissues have not been developed and relaxed by a 
previous pregnancy ; that the liability to them, and the danger 
from them, increases as the uterus is more largely developed ; 
and, also, that they are so often arrested by emptying the womb 
of its contents and securing its involution. 

Those who hold to the nervous origin of puerperal convulsions 

may be divided into two classes. The first of these recognizes in 

the pregnant state a peculiarly impressible con- 

puIrVer^UonvuTsfons.^ dition of the nervous system in which slight 
causes, not ordinarily harmful, may engender 
the most fearful consequences. This morbid " irritability," or 
convulsibility, constitutes, according to this view," a powerful pre- 
disponent of convulsions. With respect to its mode of operation, 
no very definite idea appears to be entertained , but a vague no- 
tion prevails that, in some manner, at this particular period, the 
nervous apparatus is easily deranged in its action, and that spas- 
modic and convulsive movements are thereby induced. 

The celebrated Marshall Hall proposed the rationale adopted 
by the second class. This theory holds that morbid complica- 
tions and modifications of reflex action through 

Reflex causes. „ . . 

the spinal cord are quite sufficient to explain 
all the phenomena belonging to this and to other varieties of 
eclampsia. The development of the womb during the whole pe- 
riod of gestation, but especially after the fourth month, involves 
very considerable changes in its nervous, as well as in its san- 
guineous circulation. Its afferent conductors may convey such 
impressions to the spinal center as are not capable of being 
reflected upon and appropriated by the generative system. These 
impressions, or so-called currents, which are abnormal in quality ,> 



ON THE DISEASES OF WOMEN. 23& 

and perhaps in degree also, are made to take a new direction. 
Other and remote muscles are thereby implicated, and convulsive 
symptoms result. So also of mammary, ovarian, and other varie- 
ties of excitation of the peripheral nervous filaments, which indi- 
rectly produce the same results. 

If the fit sets in during labor, the pressure of the presenting 
part, the forcible dilatation of the os uteri, an unyielding peri- 
neum, the contact of the finger of the accoucheur, or of instru- 
ments when the forceps are attempted to be applied, or of the 
hand in the operation of version, may be the exciting cause of 
impressions that are telegraphed to the spinal center, and thence 
to the medulla oblongata, to be reflected upon the muscles suc- 
cessively convulsed during the paroxysm. 

Post-partum seizures may result from the presence of clots, or 
of placental fragments retained in the womb, an incomplete fold- 
ing of the organ upon itself, or from actual displacement thereof. 

Either of these irritants applied to the sentient extremities of 
the nerves may thus indirectly originate and perpetuate the con- 
vulsive attack. As in the case cited at the beginning of this 
lecture, the fit may derange, or supersede the proper uterine con- 
tractions. Labor may be arrested, and life jeopardized, by the 
mal-appropriation of the very forces designed to consummate and 
insure them. 

The toxcemic theory refers the symptoms of this affection to the 

presence of one or more poisonous principles retained in the blood. 

Their correspondence to those of uraemia led to 

The toxaemic theory. . . ' ... 

the mierence that they might be identical in 
origin. The defective elimination of urea by the kidneys, the 
presence of albumen in the urine, and the oedema, which some- 
times occur at an advanced period of gestation, imply a state of 
convulsibility, or of liability to convulsions. The non-elimination 
of urea from the blood is believed, by Braun and others, to be the 
chief cause of the phenomena presented in puerperal eclampsia. 

The history of the renal complication in this disease is singu- 
larly interesting and suggestive. The presence of albumen in the 

urine in almost every example of puerperal con- 

The albuminuria. 

vulsions is something more than a mere coinci- 
dence. According to Blot, the average proportion of albumen in 
the urine in albuminuria without eclampsia is 83 per cent., while 



234 LECTURES, CLINICAL AXD DIDACTIC, 

in the eclamptic it may be 74 per cent. There are, doubtless, 
many cases of albuminuria in pregnant women that are not ac- 
companied or followed by convulsions, but the converse of this 
proposition is not true. As an accidental ingredient of the urine, 
a considerable proportion of albumen implies a great drain upon 
the nutritive resources of the economy. It also signifies that the 
elimination of urea is less thoroughly performed than it should be 
by the kidneys. Viewed as a premonitory symptom of puerperal 
eclampsia, albuminuria is of the utmost significance. The oedema 
of the inferior extremities, the ascites, and dropsy of the amnion, 
which are not complicated with albuminous urine, containing 
fibrin e cylinders, are not followed by urasmic eclampsia in the 
parturient state. 

Whether we regard the albuminuria as resulting in a majority 
of cases from acute desquamative nephritis, which, in this instance, 
will subside when delivery is accomplished ; or if we recognize it 
as a neurosis — a functional derangement of the kidneys depend- 
ent upon nervous causes, the meaning and the hint are equally 
obvious. So also, if it be true that kiesteine is separated from the 
blood by the kidneys, and mistaken for albumen, as Simpson and 
Bedford have suggested. It is not so much that the renal func- 
tion suffers, as that icliopathically, or symptomatically, the nerv- 
ous system is implicated. 

Whether it be the urea, the carbonate of ammonia, or some 
other primary, secondary, or tertiary product of the depurating 
process, that is dammed up in the circulation and works all this 
mischief, we may perhaps never know. That some post-organic 
material is responsible therefor is evident. That it is urea is very 
probable, and it is to the action of this noxious principle that the 
cerebro-spinal centers are especially susceptible. Frerichs, Bichat, 
Courten and Gaspard did indeed inject filtered urine, and even a 
solution of urea, into the veins of animals without ill effect. And 
there can be no question that in some cases of granular or fatty 
degeneration, of dropsy and extensive disorganization of the kid- 
ney in the human subject, the patient has shown a remarkable 
exemption from nervous and convulsive symptoms. These are 
facts of curious interest and real clinical import, but they do not 
prove that the pregnant state may not render the patient pecu- 
liarly susceptible to the toxical effect of a substance that should 



ON THE DISEASES OF WOMEN. 235 

have been eliminated. Uraemia appears greatly to augment the 
hysterical excitability of pregnant women, and 
co?JSSb?iit n y creases the to predispose them to convulsions. Simpson 
believed that " this diseased condition of the 
blood produces a preternatural excess of irritability or polarity of 
the nervous system, and more especially of the spinal system of 
nerves," in consequence of which they are more easily affected by 
the exciting causes that indirectly occasion convulsions. 

It is evident, from the foregoing remarks, that an exclusive 
view of the etiology of puerperal convulsions is not to be enter- 
tained by the enlightened and experienced 
to m n isiead usive view is apt physician. Mechanical impediments to a free 
circulation of the blood, and pressure of the 
uterus upon the vagina, the rectum, the bladder, or the stomach 
and renal vessels, may undoubtedly produce them. The same is 
true of a state of hyperesthesia of the general or local nervous 
system, and of causes which derange the distribution of nervous 
influence through the excito-motory system. Yet other attacks 
may be due to uraeniic intoxication and poisoning, of which the 
albuminuria, oedema, and general infiltration of the cellular tissue 
in successive portions of the body are the first and more prominent 
symptoms. 

I venture the suggestion that a single and significant physio- 
logical fact has been overlooked by obstetrical writers who have 
treated of this subject. Although not clearly 

Physiological deductions. ." _ _ , . . , , 

recognized and taught, it is, nevertheless, true 
that certain of the bodily tissues are especially susceptible to the 
irritation of their own post-organic products. This view is con- 
firmed in the effects of cholesterine upon the nervous system in a 
large class of diseases dependent upon hepatic derangement. 
Urea results from the destructive metamorphosis of the muscle 
tissue. The kidneys are designed for its secretion. When, by 
reason of its non-elimination, its proportion in the blood is greatly 
increased, the muscular system is likely to suffer. Cramps, spasms, 
and convulsive movements are the natural result of the irritation 
of this noxious agent, not only in the nerve-centers, but in the 
muscle-cells themselves. Grant that these cells have an inherent 
power of contractility, a point conceded by some modern physiolo- 
gists, and we can readily conceive that the direct contact of urea 



236 LECTURES, CLINICAL AND DIDACTIC, 

might produce the most mischievous consequences. It is for this 
reason, I apprehend, that in some cases the convulsions induced 
are decidedly tetanic, and in others cataleptic. Nor would the 
idea, advanced by Frerichs, that the urea is decomposed into the 
carbonate of ammonia, alter the fact, or change the inference with 
respect to the mode of its operation. Tessier, Piberet, Rilliet, 
Barthez, Picard, and others, have remarked the absence of lesions 
of the nerve-centers in those who have died of uraemia. 

Pathological Anatomy. — The post mortem record of this disease 
is not complete. The lesions noted in other organs than the kid- 
neys are incidental, and not pathognomonic. Changes in the 
structure and vascularity of the brain vary with the apoplectic 
character of the attack. The same is true of serous and sanguine- 
ous effusion within the ventricles or between the meninges of the 
brain and spinal cord. Sometimes there is a bloodless appearance 
of the brain, with diminished consistence or ramollissement of the 
cerebral mass. In most instances the heart is empty and flaccid. 
The pleurae and pericardium may be the seat of effusion. The 
lungs are sometimes pale, or ©edematous, and even emphysema- 
tous. There may be traces of abdominal and uterine inflamma- 
tion. 

In 1843 Dr. Simpson noted the first case of granular disease of 
the kidney, on post mortem inspection after the death of a patient 
from puerperal eclampsia. Numerous well- 
concomitant disease ** a authenticated cases, selected since that period, 
establish the relative frequency of Bright's dis- 
ease of this organ as a coincident affection. Braun is cognizant 
of more than thirty cases, and Hasse, Hohl, Blot, Cohen, Simp- 
son, and other authorities swell the list of those who confirm this 
observation. The renal lesions, revealed by the scalpel in cases 
of ursemic convulsions, are those proper to one of the three stages 
of Bright's degeneration of the kidney. In the first there is con- 
gestion of the organ, slight haemorrhagic effusion, the epithelium 
is not changed, but the uriniferous tubes are filled with coagulated 
or fluid exudation, in which are fibrin cylinders, discoverable with 
the microscope. In the second the kidney is increased in weight, 
is more friable, fatty, soft, and milky. This is the stage of exuda- 
tion. In the third stage the organ is shrunken, diminished in bulk 
and weight, indented, tuberculated, and of a dirty yellow color on 



ON THE DISEASES OF WOMEN. 237 

its surface. The urinary tubules are completely denuded of epi- 
thelium. This latter condition is peculiar to the chronic form of 
Bright' s disease, and is seldom witnessed in those who have died 
of puerperal convulsions. 

Much discussion has resulted concerning the origin of these 
evident symptoms of Blight's disease, revealed by autopsy in this 
form of eclampsia. Scanzoni is the champion for the theory that, 
when they do exist, they are to be regarded as among the conse- 
quences, rather than the causes, of the convulsive attack. But 
Briicke declares that " the occurrence of urasmia depends not so 
much on the intensity of the textural changes as on the extent of 
the morbid exudation of the kidneys. Christison has also shown 
that ' coma and convulsions may come on in the very earliest 
stages of Bright's disease, and that then, indeed, they advance 
more rapidly than when the degeneration is more advanced. He 
also mentions their occurrence independently of any dropsical 
effusion, and their occasionally coming on shortly after dropsy has 
been dispelled." The transient duration of the albuminuria, m 
most cases of puerperal convulsions, proves that the lesion of the 
kidney is not necessarily very deep-seated. The presence of fibrin 
cylinders, and of fatty casts, in the albuminous urine, and in the 
renal tubes on post mortem examination in the field of the micro- 
scope, is evidence that structural changes have begun, which, but 
for the termination of pregnancy, would probably in every case 
result in granular degeneration of the kidney. Simpson is of 
opinion that " albuminuria, with convulsions, etc., occurring in 
any labor later than the first, generally results from fixed granular 
disease of the kidney, and does not disappear after delivery." 

Diagnosis. — Puerperal convulsions are so likely to be compli- 
cated with hysteria, apoplexy, or epilepsy, and their nature, sever- 
ity and treatment are so modified thereby, that their differential 
diagnosis is very important. 

The hysterical convulsion partakes more of the nature of a 

spasm than of a convulsion; the muscular contractions are neither 

marked nor regular in the order of their com- 

The hysterical form. . _ 1 - . . . 

ing ; the muscles ot the trunk and extremities 
are affected to a greater degree than those of the face ; not unfre- 
quently there is opisthotonos ; there is no frothing at the mouth, 
or biting of the tongue ; no stertorous breathing, or hissing respi- 



238 LECTURES, CLINICAL AND DIDACTIC, 

ration ; no anaesthesia, with turgiclity of the features and blueness 
of the skin ; no marked increase in the frequency of the pulse 
after the beginning of the paroxysm; no gradually-increasing 
coma ; no albuminuria before the fit, and, if it is present after- 
wards, no tubular casts, fatty, waxy, fibrinous, or epithelial ; no 
regularity in the recurrence or duration of the paroxysm, which 
often ends with an emotional outbreak in the form of sobbing, 
sighing, weeping, or laughing, or with the eructation of flatus. 
It is no doubt true that many cases of hysterical convulsion have 
been mistaken for puerperal eclampsia. 

From the outset the apoplectic convulsion will be recognized 
as dependent upon intra-cranial effusion and compression. Con- 
sciousness is suspended ; sensibility is lost ; the 

The apoplectic form. 1 - 1 , . „ n . _ 

coma comes on suddenly, and is proiound with, 
stertorous breathing ; the convulsions are slight, and afford no 
reliable criterion of the gravity of the attack, the muscles becom- 
ing flaccid and powerless. 

We have already detailed the diagnosis between the true epi- 
leptic convulsion and puerperal eclampsia. In epilepsy, as in 

hysteria, the renal symptoms are essentially 

The epileptiform variety. -,.«..- . , . , 

dirterent irom those proper to puerperal con- 
vulsions. The presence of albumen in the urine, with cylindrical 
casts, has never been observed as a sequel to the epileptic parox- 
ysm. Epileptics may have Bright's disease, and during gestation,, 
labor, or child-birth, be seized with uraernic eclampsia ; but this is 
a mere coincidence. The frequent connection between the epi- 
leptic convulsions and imperfect eliminatory action of the kid- 
neys, however, led Dr. Todd to designate a variety of this disease 
as renal epilepsy (epilepsia renalis). The antecedent and co- 
existing symptoms, in a given case, would enable one to decide 
between epilepsy with renal complication, and puerperal eclamp- 
sia dependent upon uraemia. 



ON THE DISEASES OF WOMEN. 239 



LECTURE XIV. 

PUERPERAL CONVULSIONS. — CONTINUED. 

Gentleimen : 

We will resume the subject of our last lecture. 

Prognosis. — Out of 328 cases of puerperal eclampsia tabulated 
by Churchill, 70 mothers were lost, or about 1 in 4^. Wieger 
records that of 65 women seized with convul- 
sions at different periods of pregnancy, 25 died. 
Of 48 cases reported by Dr. Merriman, 37 recovered ; and of 30 
reported by Dr. Collins, only 5 died. Of the latter, three of the 
fatal cases were complicated with laceration of the vagina, one 
with twins, and one with peritonitis. Braun is of the opinion 
that 30 per cent, have proved fatal to the mother. These tables 
display varied results and are defective for the reason that no dis- 
tinction is made between the several forms and complications of 
the convulsions incident to parturition. The relative mortality 
which in Hunter's time amounted to one-half, and has already 
been so considerably reduced, will doubtless be still farther less- 
ened by a more discriminating diagnosis and rational treatment. 

The prognosis is favorable in proportion with the predominance 
of hysterical and epileptiform symptoms, especially if the convul- 
sions have not been preceded by albuminuria 

Favorable symptoms. .. ■, . „ , , . . t 

and anasarca, and if they continue synchronous 
with the uterine contractions, subsiding when the womb is emp- 
tied of its contents. Hysterical eclampsia will, other things 
equal, recover under almost any treatment, providing it is not too 
severe. In this form the attack is self-limited. 

Women sometimes have spasms and convulsions during preg- 
nancy, and afterwards escape them at " term." I had a case of 
this kind a month ago, in which my patient had 
had severe convulsions every four weeks from 
the fourth to the eighth month. When the proper time arrived. 



240 LECTURES, CLINICAL AND DIDACTIC, 

her labor commenced and was finished without any convulsive 
symptoms. Nor did she have anything of the kind subsequently. 
The earlier the advent of apoplectic symptoms, the more pro- 
found the inter-paroxysmal coma, and the implication of the brain, 
the greater the danger. This variety of the dis- 

Unfavorable symptoms. 

care may terminate very abruptly, or a single 
fit may throw the patient into a state of coma to which she shall 
succumb when one or more days have elapsed. If one pupil is 
dilated and the other contracted, it signifies a dangerous lesion of 
the brain on the side opposite the dilated pupil. It is safer to base 
our prognosis upon the condition of the patient between the par- 
oxysms, than to judge by the severity of the fits only. Drowsi- 
ness and obliviousness between the fits, where there is no coma, 
are less fatal symptoms. Mania after coma is less dangerous than 
low delirium, which latter is a symptom of puerperal pyaemia. 
Stertorous breathing is a more dangerous sign than sibilant respi- 
ration. Excessive rigors, which are in reality a species of con- 
vulsion, if frequently repeated, imply great danger. The same is 
true of syncope, collapse of features, and the coldness of the 
extremities induced by excessive exhaustion from protracted labor 
or haemorrhage. Davis says explicitly that : — " Convulsions 
complicated with profuse haemorrhage, and a fortiori if the loss of 
blood shall have been very great, should be considered as harbin- 
gers of a rapidly approaching death, the convulsions in that case 
being a part and parcel of the dying state;" — and Braun, 
44 anaemic convulsions are justly regarded as a symptom of the last 
agony." 

In convulsions occurring in twin deliveries, and in cases of pla- 
centa praevia, the prognosis is generally unfavorable. Where, 
during the later months of pregnancv, albumin- 

Serious complications. ..,.,», . n ti i « 

una with infiltration of the cellular tissue has 
existed, and the urine is nearly or quite suppressed, it implies a 
complication from which the patient is not likely to recover. If 
the renal affection is of long standing, and has already passed into 
the third stage of Bright's disease, recovery is still more doubt- 
ful. If the fits occur at longer intervals, if the amount of 
urine voided is increased, and of albumen diminished, the patient 
may get Avell after a somewhat lingering convalescence. Until 
the albumen has disappeared from the urine, however, there is a 



ON THE DISEASES OF WOMEN. 241 

liability to a sudden return of the convulsions, even when some 
days or weeks have elapsed since the last fit. " After from six to 
ten daj's, if the child-bed patient continues to go on well, there is 
generally no trace of albumen to be discovered. If during child- 
bed the albuminuria continue for weeks, it arises either from the 
admixture of pus from an acute catarrh of the bladder, or from 
nephritis metastatica, or from a far advanced destruction of the 
kidneys being present, and the Bright's disease being chronic." 

Where violent mental emotions, especially if they are depress- 
ing in character, have been at work, and the patient has been 
possessed with the idea that she is about to die 
^ Forebodings before deiiv- f convulsions in child-bed, recovery is excep- 
tional. But, as in the case cited at the com- 
mencement of the last lecture, if the fear of death follows the 
cessation of the convulsions, it is a less serious symptom. The 
alarm of bystanders is a source of great danger to those patients 
who are very impressible. 

Authorities are divided as to the relative danger in convulsions 

coming on before, during, or after delivery. Ramsbotham is of 

opinion that " convulsions coming on after labor, 

Are prae- or post-partum . n , . 

convulsions the more dan- i± the patient has not suffered an attack before, 

gerous ? 

are not so dangerous as those which arise dur- 
ing pregnancy and labor." Duges is of the same mind, and 
Churchill regards the post-partum variety nearly as manageable as 
those which occur during gestation. Churchill's worst examples 
are those in which the convulsions commence while labor is 
progressing and continue afterwards. In my opinion the most 
dangerous cases are those in which the convulsions begin with 
little or no premonition shortly after the birth of the child. 
When from twelve to twenty-four or more hours have elapsed 
after delivery, and convulsions ensue, they are almost always of 
an hysterical character, and therefore less dangerous. The only 
exception is in case of convulsions from an attack of acute 
nephritis from cold during the first fortnight of the lying-in. It 
is said that post-partum convulsions are most likely to make their 
advent towards evening, or in the early part of the night. 

Braun sums up the progress of this disease as follows: "The 
dangers of eclampsia are greatly increased by complications with 
diseases of the heart and lungs, rupture of the uterus, etc. The 

16 



242 LECTURES, CLINICAL AND DIDACTIC, 

prognosis in other kinds of eclampsia is the same as when preg- 
nancy has not occurred. Cholsemic, apoplectic, toxic, and anaemic 
eclampsias are very often fatal ; hysteric and epileptic attacks and 
chorea, almost never so." 

The danger from exposure to any of the zymotic diseases, as 
for example erysipelas or diphtheria, during the lying-in period, is 
referable to the depraved and poisoned condition of the blood, 
which renders the organism more susceptible to the action of spe- 
cific disease-producing agencies. 

The mortality of the children, in cases of convulsions occurring 
in the mother, is proportionally large. What the ratio is I am 
unable to say. In prse-partum convulsions per- 
' haps one-third of the children are lost. The 
danger to the offspring is more imminent in case the fits commence 
before labor has really set in. Under these circumstances the 
paroxysms may be very numerous before delivery is effected, 
whether artificially or naturally, and it is an exceptional case for 
the foetus in utero to survive any considerable number of them. 
The same is true where " the waters " have discharged prema- 
turely, or where for any other cause, as for example, a consider- 
able disproportion between the size of the foetal head and the pel- 
vic brim or outlet, on account of hydrocephalus, or deformity of 
the pelvis, mal-presentation, rigidity of the soft parts, uterine iner- 
tia, or profuse flooding, a prompt delivery is rendered impossible. 
Many of these little innocents are sacrificed to the obstetric expe- 
dients of version, the mal-adjustment of the forceps, and the 
more barbarous and unwarrantable resort to the perforator and 
crotchet. Given in such an extremity, ergot has doubtless slain 
its thousands. 

Concerning the actual cause of death in children under these 

circumstances, where they are not the victims of "meddlesome 

midwifery," there are differences of opinion. It 

The cause of its death. . 

has been attribted to an interruption of the cir- 
culation in the maternal side of the placenta, to the sudden shock 
from the paroxysm experienced by the mother and communicated 
to the foetus, and to poisoning of the blood contained in the foetal 
vessels. In some cases life is abruptly destroyed, while in others it 
gradually becomes extinct. Not unfrequently the child is born in 
an asphyxiated state, from which it may be rescued by appropriate 



ON THE DISEASES OF WOMEN. 243 

means. If they survive, such children are apt to be weakly and 
delicate, frail and nervous, and are not in general long-lived. Ex- 
ceptionally they are subject to spasms and convulsions from the 
moment of birth. When the mother dies in convulsions during 
parturition, the child's life can very rarely be saved, for the Cesa- 
rean section discloses that it is already lost. 

According to Braun : "If after numerous ursemic convulsive 
fits, the child is born alive, a large quantity of urea is found in 
the blood taken from the umbilical cord ; but if it is born dead, 
we can immediately after birth, demonstrate the presence of car- 
bonate of ammonia in the blood." 

Sequelae. — However gradually affected, recovery from this dis- 
ease is perfect. The exceptional cases are those in which some 
pre-existing disorder has been aggravated there- 

Secondary mental disorders. . ~ 

by, or m which the harmtul consequences 01 the 
shock to the nervous system, or of mal-treatment are perpetuated. 
A very common sequence of the attack is a species of oblivious- 
ness to what has passed, and of continued indifference towards the 
child, the father, and all her domestic interests and relations. 
Sometimes this mental aberration is of a less passive nature, and 
positive mania sets in. Under these circumstances she would de- 
stroy the infant, denounce the husband, and deny that labor has 
been completed. This form of mania is temporary, self-limited, 
and generally recovers of itself, providing the physician is suffi- 
ciently sane and determined to keep her from being sent to a 
lunatic asylum. The mental faculties are often weakened and 
impaired for a considerable time. 

Paralysis is sometimes a sequel of the apoplectic form of puer- 
peral convulsions, but it never follows true and uncomplicated 
puerperal eclampsia. The hysterical type may 
be succeeded by various derangements in the 
functions of calorification and sensibility. In rare cases the ex- 
tremities become flexed and immovable, as in catalepsy, a condi- 
tion which passes away after a few weeks have elapsed. 

Although Denman and other authors insist that puerperal peri- 
tonitis is a frequent sequel of puerperal e clamp - 

na? er d t iseas a e S and pulm °" s i a > the i^ ea * s 110 ^ confirmed by modern and 

more extended experience. Indeed there appears 

to be a greater liability to pulmonary than to puerperal disease 



244 LECTURES, CLINICAL AND DIDACTIC, 

of any kind. The pectoral affections that sometimes result are, 
the rapid development of phthisis, oedema and emphysema. 

In rare cases vision may be impaired. Amaurosis, which is a 

frequent concomitant of albuminuria, sometimes continues for 

weeks or even months after an attack of puer- 

Amaurosis. .. , . TT , 

peral convulsions. Unless consequent upon 
granular disorganization of the kidneys, or structural changes in 
the optic nerve itself, it is not a very serious affection. It some- 
times disappears entirely after recovery from the convulsive attack, 
and returns at or after a subsequent labor, even when there are no 
convulsions. Ingieby cites a case of this kind in which a patient 
" had common puerperal convulsions in her first pregnancy ; and 
who in a subsequent accouchement, was attacked with complete 
amaurosis, which continued during the whole period of her labor. 
Vision was gradually restored." 

Treatment. — It is conceded that the relative frequency of puer- 
peral convulsions depends upon circumstances which, if he is 

skillful and faithful, are largely under the con- 

Preventive Treatme?it. . . 

trol 01 the physician. In threatening convul- 
sions during pregnancy, child-birth, or the lying-in, it is of the 
greatest importance to regulate the surroundings of the patient. 

You will be obliged to exercise great tact in 
Tact. _ _ & , . & . _. . 

adapting yourselves to their several peculiari- 
ties. For it will not do to treat all alike. You can amuse one, 
while you must threaten another. You will have to be decided, 
emphatic, and sometimes even peremptory. The more emotional 
they are, the greater the need of their attention being diverted 
from themselves. Keep them busy with you. Do not let tliem 
brood over contingencies. They must be kept saying something, 
or hearing something, cheerful. If there are long-faced attend- 
ants, you had better banish them. One good, trusty nurse is suf- 
ficient. 

The room should be shaded from too strong a light, and the lamp 
or gas-light not permitted to shine directly in the patient's eyes. 

Let there be no shadows on the wall. Shut out 
ca?s e eT.° vep ° ssibleexciting tlie noise. Open the windows for fresh air. 

Prescribe the removal of all ligatures from about 
the body and extremities, for corsets, garters, etc., impede the 
circulation, and may do positive harm. Caution her against a 



ON THE DISEASES OF WOMEN. 245 

sudden check of perspiration, lest there be an additional embar- 
rassment of the renal function ; against falls, sudden shocks, 
sleigh-riding, racing, over-anxiety about domestic affairs, worry 
about finance and the future, or about her children, if she has any. 

Be careful of her diet, for indigestible food, or food which is 
too rich, may excite intestinal irritation, and provoke convulsions 
in adults in the same manner that it does in children. The case 
which formed the commencement of my last lecture is an illus- 
tration of this fact. The diet should be plain, simple, and 
unstimulating. 

The patient should enjoy the society of one or more cheerful, 

sensible friends, who, no matter what happens, will not frighten 

her out of her wits by their own conduct and 

Prescribe cheerful society. . 

counsel, -bor, it a woman who is predisposed 
to this form of convulsions, observes her own bad feelings reflected 
in the faces and actions of others, she will forthwith take alarm, 
and all your efforts at prophylaxis may fail. 

So also of your own manner and conduct in her presence. If 
you are fussy or frightened, lacking in self-reliance and resource, 

the worst possible consequences may come of 

The physician's manner. . -r TT1 ., i t i -i • r» i 

it. While, on the other hand, 11 you are calm 
and self-possessed, if you show yourself thoroughly conversant 
with this state of convulsibility and all that concerns it, you may 
and frequently will succeed in averting the danger. Under these 
circumstances, it is of the highest importance to recognize the dif- 
ferent shades of mental constitution in your patients, and to adapt 
yourselves to them. 

You should cultivate a tact in the recognition and removal of 
obscure and shadowy symptoms. These are the signals of im- 
pending danger, and they appear in every case 
drcmI lyrecognitIonofpr °" °f tn ^ s disease. If she complains of insomnia, 
do not neglect its cure. Fresh air and exercise, 
in her room and out of it, proper food and society, going to rest 
at regular hours, the avoidance of excitement and conviviality, as 
well as of too close sewing, or reading and 



"O 



For the insomnia. 

study, will otten suffice to cure the habit 01 
sleeplessness, which might otherwise result in an attack of con- 
vulsions, either at or before term. Among the remedies suited 
to the relief of this state, the more prominent are coffea, bella- 



246 LECTURES, CLINICAL AND DIDACTIC, 

donna, caulophyllin, ignatia, opinm, moschus, aconite, and hyos- 
cyamus. One of my patients, at the eighth month, complained 
that she had become exceedingly nervous and had had no good 
sleep for weeks. I learned that six weeks before, by the advice 
of a friend, she had quit drinking coffee, of which she was inor- 
dinately fond, and which had never disagreed with her. I pre- 
scribed that she should take a good cup of coffee morning and 
evening. She was cured at once. 

If she complains of headache, to which she has or has not been 
subject before, and it persists, give it your attention as one of the 

possible precursors of eclampsia. Congestive 

headache, with flushed face, dilated pupils, 
photophobia, intolerance of noise, incoherency of speech, and con- 
fusion of the mental faculties, are a class of symptoms which need 
watching, and should be remedied. Belladonna, aconite, gionoine, 
gelseminum, bryonia, nux vomica, or other similar medicines may 
be indicated. Their timely use may avert the development of the 
convulsive disorder and, so to speak, tide the patient over the 
difficulty. 

Local pains elsewhere are equally significant. Convulsions ma}' 

follow colic, gastralgia, nephralgia, pleurisy, or 
whe°re localsufferinselse " a s ilcl( ien accession of rheumatic inflammation 

of the joints. Occurring in a pregnant woman, 
after the fourth month especially, these affections should be rem- 
edied as promptly and carefully as possible. 

The same is true of a species of local anaesthesia, or paralysis of 

the sensoiy nerve filaments, in different portions 

Incipient paralysis. -11 i 1 

oi the boa}% characterized by numbness and 
tingling, or absolute insensibility, of the affected parts. 

Although there are exceptional cases in which drops}' occurring 
in pregnant women is not followed by puerperal convulsions, yet 

the rule is quite the reverse. Hence you will 
toms rthe dropsIcal symp " be on your guard whenever it occurs, and more 

especially if the oedema began in the face and 
upper extremities. For inmost cases of dropsy, whether incident 
to gestation or not, if the infiltration begins in this manner, we 
take it as a hint of renal disease or embarrassment of some kind. 
So your patient may have had a latent form of Bright's disease, 
which has been aggravated by her condition, or she may be suffer- 



ON THE DISEASES OF WOMEN. 247 

ing for the first time from an attack of acute desquamative neph- 
ritis, from congestion of the kidney, or from uraemia, due to direct 
pressure of the gravid uterus upon one or both the ureters, the 
earliest token of which may be seen in the puffy and bloated face 
and eyelids. If you act upon this suggestion you may avert the 
threatened eclampsia — always providing the degeneration of the 
kidneys has not gone too far already, and that the pressure upon 
the ureters does not cause a complete retention and resorption of 
the urine. 

Albuminuria can not take place without more or less congestion 

of the kidney. The more acute the symptoms the better the 

indication for aconite, belladonna, or nux 

For the albuminuria. . . 

vomica. When the albuminuria has existed 
for some weeks, mercuriuss corrosivus or arsenicum alb. are 
remarkably efficacious. Or apis mellifica, colchicum, hyoscyamus, 
and mere, jodatus may be required. 

In this connection I should remind you. that the patient must 

not be permitted habitually to lie upon her 

The patient's posture. .. rril , 

back. I he reasons are obvious. 
But, suppose your patient is just on the eve of a convulsive 
paroxysm. Is there no way of immediately controlling the 
symptoms ? My friend, Dr. L. E. Ober, once 

An available expedient. . . . 

told me that it was his practice, m cases of this 
kind, to instruct the women to look him directly and constantly 
in the eye, while he returned the gaze as steadily, after the man- 
ner of mesmerizers. To my certain knowledge 
this is an admirable expedient, provided you 
are healthy yourself, calm, cool, collected and confident. If, 
however, the bodily and mental conditions of the operator are 
not favorable, he may do more harm than good, and he had better 
let it alone. 

If labor has already begun and convulsions threaten, you ma} r 
sometimes ward them off by urging her to " bear down," or to 
encourage the pains. If the expulsive effort 
is slackened, the pains may " scatter." "While 
they are confined to the womb, the excess of nerve force finds 
vent through a proper channel. If they are " misplaced," she 
will be more liable to go into convulsions. 

" If at all anxious or worried, she should be reassured, not by 



Encouragement. 



248 LECTURES, CLERICAL AND DIDACTIC, 

a tiresome repetition of the hackneyed rallying cry, ' courage, 
courage, cheer up, cheer up,' but by a calm cheerful address to 
her judgment, which has far more power to inspire her with con- 
fidence in us and in the issue." * 

No matter what the period of pregnancy, if all these preventive 

means shall have failed, or if the fits have already commenced 

before j'our arrival, your first duty will be to 

Palliative treatment. 

lessen the severity of the symptoms, and if 
possible to prevent their return. 

" Until labor actually begins," says Gooch, " we have nothing to 

do with the uterus, but solely to attend to the convulsions." This 

is especially true of convulsions occurring before 

An old rule and a good ^he seventh month. For prior to that time the 

one. x 

fit is less likely to depend upon uterine irrita- 
tion and development than it is at a later period. It is for this 
reason that we often succeed in arresting these convulsions with- 
out the womb being emptied of its contents, and are sometimes 
so fortunate as to carry these patients to term without untoward 
consequences. The more decidedly hysterical the attack, especi- 
ally if it comes at the menstrual cycle, the less the danger of 
miscarriage as a contingent of convulsions. 

But since, in every case, and whatever may have been the 
exciting cause, the eclampsia usually persists until delivery is 

effected, and generally ceases as soon as the 

The induction of labor. 

foetus is expelled, it may become a question 
whether or not you should hasten this result by the induction of 
premature labor. The general opinion of the profession is 
opposed to this expedient, and there can be no doubt that great 
harm has sometimes been done by an indiscriminate resort to it, 
under the impression that, in the case of a pregnant woman 
especially, nothing could be worse than the existence and con- 
tinuance of convulsions. 

In general, and especially before the child is viable, it will be 

safe to follow Gooch's advice, and let the uterus alone. For 

nature usually evacuates the womb spontane- 

Caution. . . 

ously, if the fits do not otherwise abate in 
violence, or cease altogether. And although it may consume a 
little more time to await her slow movements than it would to 

* Puerperal Convulsions, by Prof. J. C. Sanders ; Trans. Am. Inst, of Horn., June, 
1867. 



ON THE DISEASES OE WOMEN. 249 

despatch the offending ovum secundum artem, still the patient will 
get on better afterwards and you will be better satisfied not to 
have interfered. If the os is not patulous, or the cervix uteri 
sufficiently softened, it will be better to follow Dr. Holbrook's 
example, and await the result. 

As " term" approaches, the convulsions are more serious and 

alarming than in the earlier months of gestation. The degree of 

uterine irritation is necessarily increased. But, 

When if ever justifiable. _ _ . 1 . „ 

as a critical means of relief, the induction ot 
labor is much less difficult and dangerous. The cervix uteri does 
not present so great an obstacle, and its forced expansion, by 
manual or instrumental aid, will neither wound the tissues nor 
shock the general system so severely. Hence I conclude that if 
the induction of premature labor is ever justifiable as a palliative 
in puerperal convulsions, it is where the fits are becoming so 
frequent and severe as really to threaten the life of the patient 
by apoplectic effusion or otherwise ; where the symptoms have not 
been relieved by appropriate remedies ; and where the neck of the 
womb is so dilatable that its resistance could be very readily 
overcome. These cases are comparatively rare, but they do 
sometimes occur, and we should not therefore entirely repudiate 
this expedient. For it may prevent " the loss of time where the 
loss of minutes is the loss of life." 

The means of inducing labor in these exceptional cases are, the 
introduction of the sponge tent, the warm 

Ways and means. ' 

douche, manual dilatation, and the use of 
Barnes' dilators. 

In advising you to " let the womb alone," where the convulsive 
patient is not supposed to be in labor, I do not wish to be under- 
stood as saying that an examination by the 

Note the progress of labor. . 

" touch is ever unnecessary. On the contrary, 
you should resort to it in every case of the kind, and, if the fits 
continue, repeat the examination from time to time, in order 
to ascertain if the parturient process is really going on, and how 
far it is advanced. Otherwise, and before you are aware of it, 
the labor may be finished. One of my medical friends had a case 

of puerperal convulsions at seven and a half 

Case. . 

months, in which, although the patient had 
apparently had nothing like a labor pain, the child was found 



250 LECTURES, CLLNTCAL AND DIDACTIC, 

dead in the bed with the funis wound about the neck. Apply 
the hand upon the abdomen occasionally, and to the vulva, and 
if you are obliged to leave the house before the convulsions have 
ceased, explain to the nurse, or some responsible person, that it is 
quite possible that the child ma}^ be born during your absence. 
In case the bag of waters is veiy large, we can sometimes 
stop the paroxysm by rupturing the mem- 
brfn U es- u - r thf forc e e P r em " branes and evacuating the liquor amnii. For- 
tunately in most cases, the presentation is 
favorable for the employment of the forceps. They should, how- 
ever, be carefully applied, more especially in primiparaa. 

Dr. Vines reports* the case of a patient, a primipara, aged 
twenty-eight years, who, at the eighth month, was suddenly 
seized with convulsions. " On examining the 
— cTs P e tying the bladder abdomen, the lower part was found greatly dis- 
tended, and retention of urine was suspected. 
The catheter was passed and five and a half pints of urine with- 
drawn. Great improvement of the symptoms followed. There 
was no return of the convulsions after this evacuation of the 
bladder." Copious diuresis may sometimes be induced by giving 
a few doses of aconite, hyoscyamus, or apis mellifica. 

The eccentric cause of the convulsions may be the accumula- 
tion of frecal matter in the rectum, or of clots 
cio F tr° al accumulation ; within the uterine cervix and vagina after 
delivery. The removal of these foreign sub- 
stances will sometimes afford prompt relief. 

If the fit is hysterical, it is said that you may palliate it, and 
perhaps prevent its return, by an enema of ice-water thrown into 
the rectum. The dashing of cold water upon 
the head and face is rude and uncivilized. The 
face and forehead may be bathed with it, or cloths wrung out of 
iced water may be applied to the head and to the back of the 
neck. In a case of puerperal eclampsia the celebrated Denman 
succeeded in keeping off the fits until delivery was completed, by 
sprinkling cold water on the face on eveiy accession of pain. 
Another expedient is to apply bags or bladders of pounded ice to 
the head, or the spine, or both. This is too harsh. The feet 
should be kept warm. 

* Braithwaite's Retrospect of Practical Medicine and Surgery, Part XII, p. 293. 



The use of cold water. 



ON THE DISEASES OF WOMEN. 251 



LECTURE XV. 

puerperal convulsions. — continued. 

Gentlemen : 

Those of you who were present at the meeting of the Academy 

of Medicine last evening do not need to be told that physicians 

are not agreed upon the employment of anaes- 

Anaesthetics. . . , n , , 

the tics m the treatment ot puerperal convul- 
sions. While the majority would use them indiscriminately, 
others would be more cautious ; some prefer the sulphuric ether 
to chloroform, and yet others could not be induced to prescribe 
either of them. 

I believe, however, the general impression is that, as in surgery, 
so in midwifery, the sulphuric ether is less harmful and more safe 

than chloroform. But I apprehend that in the 

Need of discrimination. 

employment of anaesthetics in puerperal eclamp- 
sia we should exercise the greatest care and judgment. For it is 
not a mere question of lessening the spasm of the muscular fiber 
and putting an end to the paroxysm, else it could be more easily 
settled. We must decide whether the attack is hysterical, epilep- 
tiform, or apoplectic. If it is hysterical, the patient will not be 
in any considerable danger of serious congestion of the brain or 
spinal cord. She may indeed pass into a state 
coSvidsTons rm_hysterical °f pseudo-narcotism, but will not become abso- 
lutely comatose. Now, although chloroform 
produces an evident hyperemia of the nerve centers, and might 
do positive harm if the case were tending toward effusion, with 
or without a clot, there can be no very serious objection to it in 
simple hysterical convulsions. It is in this form of eclampsia that 
it has been given with almost uniform success, and has achieved 
such a reputation. 

But suppose the fit is epileptiform. The more frequent its 



252 LECTURES, CLINICAL AND DIDACTIC, 

recurrence, and the greater its severity, the more profound the 
inter-paroxysmal coma. The case becomes 

ta£ c n a S r ?s indicated in cer " more anc ^ more serious. The chief danger is 
from the possible extravasation of blood, or of 
serum. Whatever means would multiply the chances of this 
result should properly be withheld. It is under these circum- 
stances that opiates are prohibited. And why ? Because they 
would be likely to overwhelm the brain and spinal cord with an 
increased determination of blood to them. If we desired to de- 
velop such a case into one of real apoplexy, we 
should give opium in substance or one of its 
salts. And since chloroform acts in a very similar manner, to 
blunt and suspend the perceptive faculties by a congestion of cer- 
tain portions of the cerebro-spinal center, it may really be just as 
harmful a narcotic in this variety of eclampsia. There can be 
little doubt that thousands of lives might have been spared if this 
view of the modus operandi and possible effect of chloroform, to 
increase the danger while it lessens the spasm temporarily, had 
been taken and acted upon before. 

If we could attenuate the chloroform and give it internally as 
we do opium, it might prove not only a harmless, but a very use- 
ful agent. The parallel which Dr. O. H. Mann 

Practical reflections. ,.-.. -iif tat 

drew in his paper read before the Academy a 
short time ago, between the symptoms observed in his cases of 
puerperal convulsions and those of a patient under the influence 
of chloroform, preparatory to a surgical operation, was very strik- 
ing and suggestive. 

In a medical convention, I once heard a physician say that chlo- 
roform was " as harmless as cold water," that it would cure any 

case of puerperal convulsions, providing you 
dogmafi e 7 r ing d folly ° f £ ave enough of it, and that its failure in this 

disease should be attributed to timidity on the 
part of the physician who administered it. Such unqualified 
dicta are sensational and mischievous. A young physician who 

was present was captivated with the idea. A 

fortnight later, he had an opportunity of putting 
it into practice. He afterwards called upon me and frankly stated 
his experience and his convictions. He had given chloroform of 
an excellent quality to an almost unlimited extent, in a case of 



ON THE DISEASES OF WOMEN. 253 

post-partum convulsions. At first it lessened the severity of the 
paroxysms, but after some hours had no apparent effect in con- 
trolling them, and his patient died of apoplex} 7- . He recalled my 
lecture upon this subject when he was a member of the college 
class, and thanked me for the advice never to 
administer chloroform in a case of puerperal con- 
vulsions if there is a manifest tendency to apoplectic effusion, but 
more especially if that effusion already exists. 

If you can not determine beforehand, in a given case, whether 
the anaesthetic would be beneficial, it may be well to let the pa- 
tient inhale a little of it, by way of experiment. 
If its effects are such as they should be, you 
can continue its administration, otherwise it may be withdrawn. 
Sometimes we fail with chloroform, and afterwards succeed with 
sulphuric ether. 

Dr. W. H. Holcombe, of New Orleans, reports* the following 
interesting case of a stout young negro woman 
c chloroform per an um- w i 10 j^ j^ convulsions in her first labor, but 
who had escaped them in her second labor : 
" Twenty days after her confinement 1 was called in great ur- 
genc}^ to see her. The overseer reported that she had been doing 
well up to that morning, although he had noticed considerable 
swelling of the face and legs for two or three days previous. In 
the afternoon she complained of a very severe headache, and 
toward sunset went suddenly into a violent spasm. I saw her 
about eleven P. M. She had had nine convulsive paroxysms, and 
was perfectly comatose. There was stertorous breathing, and 
great and alarming tracheal rattle. Whilst I was examining her 
she became convulsed. The muscles of the face were twitched 
with inconceivable rapidity, the limbs participating in the con- 
tortions ; respiration was entirely suspended, and the whole bed 
shook with the violence of the movements. It lasted about one 
minute, when relaxation took place, followed by increased 
tracheal rattle and very labored respiration. Bloody, ropy mucus 
had to be extracted with the finger from the mouth. She was in 
a state of profound coma, and deglutition was impossible. 

" Having no confidence whatever in the lancet in such cases, 
although the pulse was full and corded in the interval, or in cold 

* North American Journal of Horn., Vol. IX, p. 277. 



254 LECTURES, CLINICAL AND DIDACTIC, 

douches, or sinapisms, or anything else which is calculated to 
increase reflex action, I determined to administer chloroform by 
the rectum. * * * * I can not imagine that she could have 
survived another convulsion, so thoroughly asphyxiated was she 
by the last one. The paralysis of the medulla oblongata, the 
great respiratory ganglion, or ' vital knot,' appeared almost com- 
plete. I dissolved two tablespoonfuls of brown sugar in about a 
gill of lukewarm water, added a tablespoonful of chloroform, drew 
it up once or twice into the tube, forcibly ejecting again, so as to 
disseminate the chloroform throughout the mass of water, and 
then injected the whole into the rectum, causing it to be forcibly 
retained by a napkin pressed between the nates. 

" No more convulsions occurred ; the remedy had acted like a 
charm. She relaxed into an apoplectic stupor, which became less 
and less stertorous by degrees, until in two or three hours, the 
respiration and pulse were natural. She did not speak for nine 
hours, and then only in monosyllables. She did not recover con- 
sciousness in full for twenty-four or thirty hours after the last 
paroxysm. In three days all signs of oedema had disappeared, 
and thenceforward the patient made a rapid recovery. She re- 
membered nothing which had occurred since the headache of the 
first day. 

* * * * "I think it was eminently fortunate that I used 
the chloroform by injection into the rectum and not by inhala- 
tion, and I strongly recommend my profes- 

Practical inferences. . 

sional friends to try that mode m the future, 
and for this reason : In puerperal convulsions the aerating function 
of the lungs is greatly impeded, and it is very desirable that as 
much oxygen as possible may enter with each inspiration. The 
patient's life depends upon it. Any aeriform substance taken 
into the lungs, however valuable in a medical point of view, must 
mechanically occupy space which had better be pervaded by 
atmospheric air. The chloroform injected into the rectum exerts 
its specific action on the nervous system just as well (perhaps, 
indeed, better, for the nerves of organic life no doubt preserve 
their sensibility long after that of the nerves of animal life is 
apparently obliterated by the convulsive paroxysm), and the 
oxygenating power of the air is preserved as far as possible." 
Of late frequent allusion is made in the medical journals to the 



ON THE DISEASES OF WOMEN. 255 

power of veratrum viride to arrest and control the fits in puer- 
peral eclampsia. If the half that has been 

Veratrum viride. ,.-,„..,. . -, , -, 

claimed lor it in this respect is true, it should 
sometimes be a valuable remedy. I have had no experience with 
it, but will cite you quite a marked case communicated to me 
some months ago by my friend, Dr. W. H. Burt : 

" In the case of a plethoric young woman, a primipara, the 
cause was doubtless psychical. The husband became intoxicated 
and was discharged from the only position he 
could fill, the very day his wife was confined. 
The labor was natural, but a little tedious, the waters having es- 
caped the day before. She was delivered at 4 a.m., and no lady 
ever did better than she until 4 p.m., when her husband came 
home greatly 'excited and told her all his troubles. At 9 p.m., I 
was sent for in great haste. Found my patient sitting up in bed, 
pressing the sides of her head with her hands and exclaiming, 
' My head is so full it will burst.' For two hours I gave her bel- 
ladonna 2d, every half hour. Then she went into a violent con- 
vulsion. The face became livid, the pupils dilated ; she frothed 
at the mouth, and passed into a profound coma, from which it 
was impossible to arouse her. I gave opium 2d for two hours, 
and afterwards the same remedy in the third dilution, letting her 
inhale chloroform meanwhile. In spite of my efforts, continued 
from ten in the evening until seven in the morning, the fits were 
at no time more than fifteen minutes apart. Most of the time, 
indeed, they recurred every five minutes. Hyoscyamus was also 
tried, but without effect. 

"At 8 A.M. I commenced giving eight drops of the fluid extract 
of the veratrum viride, repeated every half hour. After the third 
dose vomiting set in. She had but three paroxysms after com- 
mencing the remedy. Drop doses were then given at intervals 
of two hours. She became rational the second day, and made a 
good recovery." 

Concerning the employment of the lancet for the purpose of 
lessening the severity of the fit, and of doing away with the pos- 
sible consequences to the brain and spinal cord, 

Venesection. , . . -. „,, 

authorities are not agreed. I here are those 
who would bleed in all cases whatsoever, and, on the other hand, 
those who could not be induced to try it at all. It is possible that 



25G LECTUBES, CLINICAL AND DIDACTIC, 

the reaction against the use of this expedient, in exceptional cases, 
may have gone too far. As a means of mechanical relief to the 
surcharged vessels of the brain it may, perhaps, be more direct 
and available than any other. For it is really no argument against 
its employment to say that the indiscriminate abstraction of blood 
in puerperal diseases has slain its thousands. I have no experi- 
ence of my own to relate, but will cite you the following cases 
communicated to me by the late Dr. Geo. W. Perrine, of Mil- 
waukee : 

" Mrs. , a young woman, primipara, of rather full habit, 

was seized with convulsions four hours after delivery. Nothing 
had occurred to attract attention during labor 
except that she was more quiet than usual, and 
that, although she evidently suffered a great deal, she made but 
little outcry. During the first convulsion the pulse was not 
remarkably strong, but its strength increased so decidedly that 
after the third fit I bled her about twelve ounces. The pulse 
became less strong, the convulsions ceased and did not return for 
several hours. I went home, but was summoned to her again, to 
find that the fits had returned. I bled her again, this time from 
both arms, the blood being thick and dark, but had not drawn 
more than half as much blood as before, when the muscles became 
relaxed, the face pale, and the compulsions ceased entirely. After 
about six hours consciousness was restored. She was oblivious to 
all that had passed since the first paroxysm. By the employment 
of proper means she had a rapid convalescence." 

" About three months after this, my friend, Dr. J. S. Douglas, 
had a case of convulsions during labor. The patient was young 
and very robust. The fits recurred with each 
labor pain. When I first saw her she had had 
several of them ; was wholly unconscious ; the face was swollen, 
flushed, and of a purplish hue ; the eye-balls protruded ; the pulse 
was slow, full and strong ; the respiration stertorous, with froth- 
ing at the mouth during expiration. On consultation, it was 
determined that I should bleed her. I took about twenty ounces, 
when her pulse lowered, the turgiclity and leaden color of the face 
subsided, the convulsions ceased entirely, and she made a safe and 
speedy recovery." 

I have witnessed good results from the domestic expedient of 
applying sinapisms to the calves of the legs. In 

M?s°urd Stic expedients— two cases of convulsions, occurring at the sixth 
month, they served to stop the fits entirely, even 

when the most appropriate internal remedies had failed. 



ON THE DISEASES OF WOMEN. 257 

In case the congestive tendency is very marked, dry cupping 
may sometimes afford temporary relief. It has 

Dry cupping— Camphor. . 

the merit ot being harmless, and is always 
available. In the hysterical form, camphor given by inhalation 
or internally, sometimes acts like a charm. 

You should in no case fail to examine into the condition of the 
os uteri and the perineum. If the former is rigid or exceedingly 

sensitive, measures addressed to its relaxation 
utS r an<P d ^eum he ° s an( ^- paralysis may prevent or put an end to the 

eclampsia. It may answer to give the patient 
a few doses of belladonna, or of gelseminum, or, if you prefer, to 
dilate the unyielding cervix with your index finger, or by the local 
application of sweet oil, or of the extract of belladonna, mixed 
with equal parts of lard, or by the vapor of chloroform directly 
applied, or by warm water injected into the bowels, or a constant 
stream of warm water, thrown from an Essex or a similar syringe 
into the vagina. Sweet oil, or lard, or the belladonna ointment 
may be applied and rubbed into the perineum, if necessary, but 
you should remember that too much manipulation, more especially 
too firm pressure of the hand upon it, may serve to increase the 
severity and frequency of the fits. A good rule in making appli- 
cations designed to relax the perineum is to place them in contact 
with the mucous surface of the part. By the same rule, if you 
apply the belladonna ointment to the inner instead of the outer 
surface of the uterine neck, it appears to act more promptly and 
efficiently. 

If labor is progressing, the soft parts are dilated or dilatable, 
and the presentation and position of the foetus are favorable, it 

would be best to finish the delivery as speedily 

Rule for use of the forceps. . . , 

as possible, in the hope that, the uterus being 
emptied, the fits would not return. In general, the forceps are 
not to be applied in case there is any considerable spasm and 

rigidity of the os uteri. This is the rule ; but 

Exceptions. . 

there are exceptions to this rule also, ior 
example, you may have a case in which the anterior lip of the 
uterine cervix is so unyielding as to interrupt labor and perpetu- 
ate the convulsions. The forceps are contra-indicated, and the 
convulsions may continue indefinitely. Let me tell you how I 
managed a case of this kind: 
17 



258 LECTURES, CLINICAL AND DIDACTIC, 

Case. — On April 14, 1864, at eight a.m., Mrs. , primipara, 

was seized, while dressing for breakfast, with a severe labor pain, 
in consequence of which " the waters " escaped suddenly. She 
was placed upon the bed, and with the next pain, which came on 
within five minutes, she went into a convulsion. When I arrived 
she had had three paroxysms, and they continued to recur with 
each pain. The "touch" revealed the os high up towards the 
promontory of the sacrum. It was dilated to the size of a shil- 
ling, and its anterior lip was thick, hard and unyielding. 

At eleven a.m., the symptoms had not changed materially. The 
fits were repeated as often as once in from five to seven minutes, 
and she remained comatose in the intervals. Prescribed bella- 
donna 3d, to be repeated every fifteen minutes, and resolved to 
await further dilatation. 

At three p.m., my colleague, Prof. A. E. Small, was called in 
counsel. When the patient was placed upon her back in bed, 
only the anterior lip of the cervix could be felt, but when upon 
the side, we were able to recognize the vertex in the vicinity of 
the sacro- vertebral angle. The os uteri was now about the size 
of a quarter of a dollar. The convulsions and coma continued 
as before. We concluded that it would not be safe or expedient 
to attempt the use of the forceps. Continued the belladonna at 
intervals of half an hour. Chloric ether to be inhaled at the com- 
mencement of each paroxysm. 

Met again at eight p.m. Very slight change. The os uteri 
dilated to the size of a silver dollar, and the soft parts dry, hot 
and tumefied. The anterior lip, however, was as prominent, rigid 
and unyielding as in the morning. She was totally unconscious, 
and the convulsions quite as severe and frequent. An attempt 
was made to apply the forceps, the patient lying upon the back 
with her hips to the edge of the bed ; but it was unsuccessful. 
This expedient was therefore abandoned until further dilatation 
should take place, and my friend, the Doctor, left me for the night 
at nine o'clock. 

On subsequent reflection, I resolved that something must be 
done forthwith ; for I feared that either the cervix uteri might be 
torn off, as has sometimes happened, or my patient's life sacrificed 
to protracted delay on my part. Since it was impossible to apply 
the forceps with the patient in the usual obstetric position, I deter- 
mined to try and adjust them while she was lying upon the left 
side, with the limbs flexed, in the position recommended by the 
old English authors. In a little Avhile I had the satisfaction of 
passing both blades of the instrument quite Avithin the cervix and 
locking them properly. By careful manipulation, I soon delivered 
her. The child was still-born. For twenty-four hours the fits 
came, at longer intervals, and finally ceased altogether. Con- 



ON THE DISEASES OF WOMEN. 259 

sciousness was not restored until the fourth day. She made a 
good recovery. 

Three years later this woman had a living child at term, with 
less than half a dozen pains, without any convulsions or other 
untoward symptoms. Indeed, her labor was so brief that all was 
over before I could reach her bedside. 

You may even be justified exceptionally, for example, in case 
of extreme rigidity, with long-continued and dangerous convul- 
sions, in attempting the application of the for- 
Appiying the forceps ce p S w ithin the cervix uteri before it is suffi- 

within the cervix, ± 

ciently expanded to permit the head to pass. 
But before doing so, you should be very certain that your patient 
has reached "term," that the "waters have broken," that the 
head is below the superior strait, that you have a presentation of 
the vertex, and that she is actually in labor. Here is a case in 
point : 

On the 24th of March, 1868, at seven p.m., my friend, Dr. E. 

Kniepcke, of this city, was called to visit Mrs. , aged 28, 

who was in labor with her first child. She had 
already been in labor for three days and nights. 
Four physicians and as many midwives had been successively in 
attendance. In order to put a stop to her pains and to the con- 
vulsions also, the last of those who had preceded Dr. K. had given 
the patient, by actual weight, one and a half grains of morphine ! 
The amniotic liquor had escaped with the first pains. 

For twelve hours the fits- had recurred as frequently as once in 
five minutes. The os uteri was rigid, hard, and of about the size 
of a half-dollar. So much of the uterus as the basin could con- 
tain was prolapsed into the pelvic cavity. 

I saw the patient at Dr. K.'s request, at half-past nine P.M. She 
was in a semi-conscious state between the pains and the convul- 
sions, which were synchronous. The margin of the os uteri was 
thick, well defined all around, and cartilaginous to the touch. It 
rested on the perineum. The soft parts were hot, dry, and very 
much swollen. In reality the os uteri felt like an ivory ring of an 
inch and a half in diameter, and half an inch in thickness, placed 
directly around the presenting vertex. These symptoms were 
verified by our private pupils, Messrs. Dorion and Poppe. 

We applied the extract of belladonna, mixed with lard, to the 
rigid cervix most thoroughly, and then determined to attempt 
the use of the forceps. By my direction, the patient's hips were 
brought to the edge of the bed, and she was placed in position as 
in ordinary forceps cases. Chloroform was then administered by 



260 LECTURES, CLINICAL AND DIDACTIC, 

Dr. K., to the extent of complete anaesthesia. Having warmed a 
Naegele's forceps, and anointed the back, or external, surface of 
both blades with the belladonna ointment, I proceeded by careful 
and continued manipulation to introduce the right-hand blade. 
When it was finally applied, this brought the os uteri into the 
shape of a button-hole, and filled it completely. It was only by 
persevering effort, stretching the orifice with the blade on the one 
side and the finger on the other, that it was made possible to insin- 
uate the second blade at all. 

The instrument was finally adjusted in the direction of the 
occipito-mental diameter of the child's head, and the delivery 
accomplished. The utmost precaution being taken, the soft parts 
sustained no injury, and the woman recovered without any unusual 
symptoms, having survived the prolonged suffering and the eclamp- 
sia, not to speak of the morphine, six doctors, two medical stu- 
dents, and four midwives. 

At the recurrence of the fit, a thick piece of india rubber, or of 
soft wood, should be placed between the teeth, in order to protect 
the patient's tongue. She should not be held forcibly or firmly 
to the bed, but simply prevented from throwing herself upon the 
floor or otherwise inflicting bodily injury. Too much constraint 
might increase the difficulty, and would do no good. If she has 
an antipathy to the nurse, the husband, or any one in the room, 
you had better send them out. And do not let bystanders give 
vent in her hearing; to exclamations of fright and horror at the 
contortions of which they are witnesses. 

Curative Treatment. — Having faithfully carried out the direc- 
tions that I have given you, the application of remedies to the 
treatment of puerperal convulsions is very much narrowed down 
and simplified. If you bear in mind that its hysterical, epilepti- 
form, and apoplectic complications and terminations are the chief 
peculiarities of this disorder, you will have the key to its special 
therapeutics. For, whatever may be said to the contrary, one or 
more of these three incidental ailments will, in every case of puer- " 
peral eclampsia, give rise to the symptoms that you are to treat 
medicinally. There is no remedy for the disease per se, and no 
specific for either of its different varieties and modifications. 

If the predominant symptoms are hysterical, a careful study of 
them will be likely to show that one of the following remedies is 
indicated: belladonna, ignatia, hyoscyamus, camphora, chamo- 
milla, moschus, pulsatilla, stramonium, coffea, or gelseminum. 



ON THE DISEASES OF WOMEN. 261 

If they are epileptiform, under the appropriate indications, which 
you have learned from my colleague, the Professor of Materia Med- 
ica, you may prescribe cuprum, mix vomica, nux moschata, gelse- 
minum, secale cornutum, colchicum, ignatia, or stramonium. 

If they are apoplectic, aconite, belladonna, veratrum viride, bry- 
onia, opium, or glonoine. 

It has been claimed that some particular remedies are especially 

efficacious in certain potencies, as, for example, belladonna in the 

twelfth or thirtieth attenuations, and stramo- 

A fallacious dogma. .. .. 

mum m the two hundredth, when they are pre- 
scribed in the treatment of puerperal convulsions. Let me caution 
you, however, against the one-sided view that would commit you 
to the exclusive use of these or the lower potencies. Opinions of 
this kind, when they are based upon the experience of individual 
practitioners merely, as they always are, are more suggestive than 
satisfactory ; for, in truth, no single obstetrician has treated a suffi- 
cient number of cases of this disease to warrant him in asserting 
that such is the fact, or in laying down such a rule for the guid- 
ance of others. 

It is sometimes so difficult for these patients to swallow the 
medicine in a liquid form that you will do well to prepare it for 

them in the form of powders or pellets. By 

How to give the remedy. . -. . , , 

this means it can be given dry upon the tongue. 
Whatever fluids are administered should be introduced into the 
mouth very slowly and cautiously, else they may strangle the 
patient, and thus cause an unnecessary repetition of the fit. 

In the subsequent treatment, it is very important to keep the 
patient well nourished ; to avoid unnecessary excitement ; to have 
the breasts well drawn, either by the child or artificially ; not to 
permit the lochia to cease suddenly ; to keep the bowels and blad- 
der free from excessive accumulation ; and, if there are symptoms 
of amaurosis, to protect the eyes from too strong light. 



262 LECTURES, CLINICAL AND DIDACTIC, 



LECTURE XVI 



MENSTRUAL HEADACHE. 



Gentlemen : 

Having heard a good report of our Clinique, this poor woman 
presents herself for treatment. 

Case. — Mrs. , aged 40, began to menstruate when she was 

only twelve years old. About that time she commenced to have 
periodical attacks of headache, which, she says, have always 
returned just before or just after the " courses." She is the 
mother of three children. With the exception of the time in 
which she was pregnant and while nursing her children, in each 
case, and also when, for some unknown reason, the menses were 
suppressed for twelve months at another time, she has never failed 
in twenty-eight years to have this headache every four weeks. 
The arrest of the catamenia took place two years ago, and afforded 
a complete immunity from these attacks. When the flow was first 
restored it was slightly irregular in its return, but the headache 
came on again, and since that time it has been more severe in 
degree than ever before. 

The pain is located in the temples, and across the frontal region, 
is aggravated by light, but not by noise. It occasionally, although 
very rarely, happens that a paroxysm is caused by over-fatigue and 
anxiety. During the attack she sometimes has slight nausea, there 
is occasional vomiting, weakness, a feeling of inability to stand or 
walk, and a very decided anorexia. She has consulted many phy- 
sicians, but without benefit. 

These few symptoms convey no very adequate idea of the suf- 
fering involved in the monthly martyrdom to which our patient 

has been subjected for more than a quarter of a 
queS ovwiookSd fre_ century. The case is by no means a rare one. 

There are those who have had this painful affec- 
tion during their whole menstrual life. And, strange to say, it 
frequently happens that this particular variety of headache is 



ON THE DISEASES OF WOMEN. 263 

often improperly diagnosticated and treated. I have seen patients 
who have been under the professional care of a number of physi- 
cians for this complaint, and although the monthly periodicity of 
their symptoms was as marked as in the case before us, no refer- 
ence had been made to it at all. 

The especial significance of the different kinds of headache that 
are incident to the sexual diseases of women is not as thoroughly 
understood by the profession as it should be. I can not hope to 
remedy this defect in their special pathology, but I desire to offer 
a few practical hints that are founded upon clinical experience. 

Nearly, if not quite all, these forms of cephalalgia are of reflex 

origin. The only prominent exception to this rule occurs in case 

of the impairment of the quality of the blood, as 

Reflex headache. . . . _ _ 

m chlorosis, cnloro-ansemia, the debility follow- 
ing abortion, menorrhagia, uterine leucorrhoea, or too prolonged 
lactation. The "menstrual headache," as it is termed, is almost 
always dependent upon ovarian irritation or inflammation. Hence 
the relation of the paroxysm to the return of the menstrual cycle. 
It comes regularly each month. It may either anticipate, accom- 
pany, or follow the discharge. The pain is most frequently 
located in the crown of the head, or it may be in one or both 
temples, in the orbital region, or even in the back of the head. 
It may or may not be accompanied lyy the " clavus hystericus." 
In chronic cases, it is sometimes described as " crushing, as if 
there were great weight upon the vertex." This is an intractable 
and persistent symptom, especially in women who are passing 
through the climacteric period. More frequently, perhaps, the 
pain is said to be "burning" in character, and circumscribed in 
extent. 

It is quite common for women with this kind of headache to 
complain of " strange " sensations in the head, or of " forgetf ill- 
ness ; " or they will tell you that " half the 

Peculiar symptoms. . 

time they do not know what they are about. 
Sometimes, during the paroxysm, they will threaten to " go 
crazy," and, nolens volens, m.s.j put the threat into temporary 
execution. This is the form of headache with which those who 
are subject to difficult and delayed menstruation are most afflicted. 
Those who are of the hysterical or the neuralgic diathesis are par- 
ticularly liable to it. When it occurs as a concomitant of uterine 



264 LECTURES, CLIXICAL AND DIDACTIC, 

ulceration, I think yon may refer the lesion of the cervix and the 
headache to some primary disease in one or both of the ovaries. 

Attacks of headache which are incident to uterine displace- 
ments and to leucorrhcea, resemble what is vulgarly styled " sick 
headache." In this form of the disorder, the 

Headache from uterine . 

displacement and leucor- paroxysms recur without regularity and with- 
out any special reference to menstruation. In 
those who are susceptible, over-fatigue, want of proper rest, or of 
food, or an excess of mental excitement, may induce it. Here 'the 
gastric function is prominently and principally implicated. Inci- 
dentally, the most curious S} T mptoms may attend it. One of my 
private patients described the feeling in her head as " a sort of 
wriggling, as from the movement of long worms, such as are 
found in vinegar." It is not unusual for such persons to com- 
plain of a sensation " as if the head had been scalped, and the 
brain left exposed." 

I once knew a woman to be confined to her room for fifteen 

consecutive weeks with a spurious typhoid fever. In her case, 

this headache returned every fifteenth day with 

Case. " 

the regularity of an ague. Her description of 
the paroxysm led me to infer that there was a possible dislocation 
of the uterus, although it had never been suggested to my patient 
by her previous medical attendant. I found that the womb had 
settled down upon the perineum. As soon as it was restored, the 
periodical headache vanished and her fever did not return. If we 
except the expedient of setting fire to the house, nothing will 
place some of these patients uj)on their feet so speedily as to re- 
store the womb to its proper position, and to keep it there. 

There is a prevalent idea that the menstrual headache is caused 
by a spasm or obstruction of the uterine cervix, which has the 

effect to prevent a ready exit of the menstrual 
ache. useofmenstrualhead " fl° w - In exceptional cases, this, may be true ; 

but the reverse is certainly the rule. If it were 
not so, labor, either in abortus or at term, and indeed, whatever 
would secure the free expansion of the cervix, would cure it radi- 
cally and entirely. But this woman's history disproves the theory 
of its being due, in her case at least, to a lesion or spasm of the 
neck of the womb. She has had three children, and now is worse 
than ever before. 



ON THE DISEASES OF WOMEN. 265 

Here the direct relation of the headache to the function of ovu- 
lation is shown, not only by the regularity of its return at the 
month, but also by a complete exemption from 

Proof of connection be- 

tween ovulation and the it during gestation and lactation. In preg- 

cephalalgia. ° & r £> 

nancy, and while nursing, menstruation is 
physiologically suspended. When this function was arrested the 
headache ceased, and when it was resumed the headache returned. 
The same was true of the period during which, for some unknown 
reason, she had amenorrhea. The periodical afflux of blood to 
the generative organs, but more especially to the ovaries, and the 
nervous tension and erethism connected with the monthly crisis, 
appear to have been sufficient to cause the headache. As soon 
as the vascular and nervous energies were diverted and busy 
elsewhere, — in the developing uterus during gestation, and in 
the mammary glands while nursing her infant, — the remote 
cause was removed, and the effect ceased. 

This view of the etiology of "menstrual" headache is confirmed 
by the history of cases in which an incidental and temporary 
excitement of the generative system causes an 
whTcttfmu1a?e°o I vuTado e n. attac k independently of, and without reference 
to the monthly return. There are those who 
always have it after coitus. In some it follows the first indul- 
gence of the sexual act after menstruation, or 

Exciting causes. -i i • t 

prolonged continence. In others, a sexual or- 
gasm induced by emotional influences, especially if it is ungrati- 
fied, may be followed by a severe attack of this peculiar form of 
headache. Incompatibility in the marriage relation is a frequent 
cause of it. It is sometimes due to a temporary arrest of the flow 
for a few hours, or rather to what has been styled " intermittent" 
menstruation. Or it may depend upon too scanty or too copious 
a discharge. In brief, in certain women, whatever mental or 
physical causes are sufficient greatly to derange the circulation 
and innervation of the internal generative organs are capable of 
inducing the " menstrual headache." 

Suppose we interrogate this patient a little farther, and ascer- 
tain if there are not other symptoms with which we should become 
acquainted. 

" Are you quite well, madam, with the exception of the head- 
ache ? " kt No, sir, not entirely ; but the pain in my head, when 



266 LECTURES, CLINICAL AND DIDACTIC, 

it does come on, is so much worse than anything else, that I make 
no account of the other symptoms." " What other symptoms 
have you ? " "I have a feeling, sir, as if my limbs were going to 
sleep. It requires a great effort for me to keep about, and I am 
very sensitive to the cold air." " Do you have these symptoms 
now, midway between the periods ? " " Yes, sir." " Tell me 
how you feel when the flow commences, and while it continues." 
"I often have a kind of spasm in the bowels, which comes on just 
before the discharge begins, and then goes off again. Sometimes 
I become a little blind, and so long as I am sick there is more or 
less darkness before the eyes, so that I can not see distinctly." 
"Do these last symptoms disappear as soon as the flow stops?" 
" They do." " Show me where the pain is located." " It is here, 
sir, in the left side, right over the hip. Sometimes it is in the 
groin, and shoots down that leg ; at other times, saving your 
presence, it passes into my belly. And sometimes there is a 
throbbing in the lower part of my back-bone." " Are you quite 
certain that these symptoms return every time you are sick ? " 
" I am, sir ; they are as sure to come as the flow itself." 

Now, gentlemen, if there have been any doubts in your minds 
as to the interpretation of this case, I think they will have van- 
ished with the close of this examination. You 
ies1on rch f ° r the prImary ma 7 sometimes find it even more difficult to 
locate the original lesion which has given rise 
to a sympathetic headache, such as that of which our patient com- 
plains ; but you should always search for it. For, depend upon 
it, although you may fail to remedy an obscure case, if you can 
explain its special pathology, its cause, course, nature, and prob- 
able termination, you will have almost as strong a hold upon the 
confidence of the patient and her friends as if you were really 
able to cure it. 

There is no especial difficulty in diagnosticating this from other 
varieties of headache. The "sick" headache affects males and 
females indiscriminate ly, and sometimes affects 
he?dafhe! is_from " sick " <l uite y° un g children also. It is not regularly 
paroxysmal. The fits have no especial relation 
to the menstrual c} r cle, but may be brought on at any time by an 
excess of anxiety, fatigue, or the eating of improper food. The 
paroxysm passes off with sleep, or is relieved by pressure, as from 
a handkerchief bound tightly about the head, and sometimes ends 
with emesis. The gastric function is chiefly deranged, and 



ON THE DISEASES OF WOMEN. 267 

nausea, retching, and vomiting almost always attend it. It may 
occur prior to puberty, and also after the climacteric. In many 
women the paroxysms of this headache are more frequent during 
the early months of pregnancy and lactation than at other times. 
Those who are subject to it are apt to be wretched and hypochon- 
driacal. It is sometimes cured by change of climate. 

The " neuralgic*' headache is traceable to vicissitudes of 
weather, unusual exposure, especially to wet and cold, prolonged 

mental strain, insufficient nourishment, nervous 
^j-rom" neuralgic" head- exhaustion and perturbation of the mental 

faculties. Unless of a regular intermediate 
type, as in orbital neuralgia, or u sun" headache, it does not recur 
regularly, and has no especial relation to the menstrual function. 
It is often relieved by eating or drinking. The rheumatic dia- 
thesis is a strong predisponent of this variety of headache. Seam- 
stresses and others who live upon a light and insufficient diet, 
who are underfed and overworked, and who drink much of tea 
and coffee, are very liable to it. It is sometimes caused by 
decayed teeth. The pain is piercing, darting, lancinating, and 
erratic, sometimes present in one part of the head or the face, and 
again in another, now superficial, then deep- seated. 

The " congestive" headache, of which one sees more in the 
medical books and journals than in actual practice, is marked by 

a flushed face, redness and suffusion of the con- 
heSa?he. U congestive junctivse, either dilated or contracted pupils, 

photophobia, an intolerance of noise, and a full 
pulse. This form of headache is usually a concomitant of some 
local inflammation, and subsides without any very serious con- 
sequences. 

The " hysterical" headache differs from those of which I have 
spoken, in the period of its occurrence and recurrence, in the 

fixed limit of its location, in the fitful flow of 
ach e ° m " hystencal " head " animal spirits which accompanies it, and in the 

marked effect that the most trifling emotional 
influences have to increase the suffering. It is very likely to 
recur at the month, more especially if the patient has dysmenor- 
rhcea, or spinal irritation, but is not by any means confined to that 
particular period. Some women always have it if the menses are 
delayed or suppressed. In other cases it is a sequel to menor- 



268 LECTURES, CLINICAL AND DIDACTIC, 

rhagia. The paroxism may be caused, and may come and go, in 
the same manner as the true hysterical fit. 

The proper " menstrual" headache returns with the regularity 
of an ague paroxysm every time the woman menstruates. If its 

habit has been to come on at the beginning of 
stm^'headTche^ 6 ' men " tne monthly crisis, this habit will be persevered 

in. If it has been accustomed to return at the 
last of the month, just as the flow has almost entirely ceased, you 
may expect it again at the same season. If your patient menstru- 
ates once in three weeks it will not fail ; if e\ T ery six weeks she 
will not escape it. Nor does it matter if she has had an incidental 
attack during the inter-menstrual period. It will be all the same, 
whether sooner or later, whenever ovulation takes place. Preg- 
nancy, lactation, amenorrhcea, the climacteric, or whatever inter- 
rupts the menstrual function, will arrest it. When this function 
is restored, it will come again. The degree of suffering in the 
head is not always in ratio with the quantity of blood that is 
lost in menstruation, neither with the intra-pelvic pain and dis- 
tress that are experienced in getting rid of it. The quasi-hysteri- 
cal symptoms which sometimes attend upon attacks of this head- 
ache, are incidental merely, and not at all characteristic. In the 
majority of cases a close and careful examination reveals either 
sub-acute or chronic inflammation, irritation, or neuralgia of one 
or both of the ovaries. 

The prognosis will vary with the age, temperament, and sur- 
roundings of the patient, the nature and duration of the sexual 

disorder, the possibility of controlling and direct- 

The prognosis. , . . 

ing her emotional states and the condition ot 
her general health. Chronic cases are not so readily cured as 
those which are more recent, and therefore less complicated. The 
nearer the approach to the climacteric, the less promising the 
case. When the menses cease, however, the headache will prob- 
ably stop of its own accord. Frequent child-bearing, but more 
especiallv frequent abortions, render this disease more intractable 
than it is under opposite circumstances. Domestic infelicity is an 
almost insuperable obstacle to the cure of this form of headache. 
The periodical engorgement of the ovaries, which is contingent 
upon menstruation, lights up, renews, and perpetuates the lesion 
of those organs, whatever it may be. If we can prevent the 



ON THE DISEASES OF WOMEN. 269 

monthly exacerbation of the sexual disorder, and can so regulate 
this function that it shall become physiological and healthy, the 
cure is practically accomplished. Otherwise, the disease may 
continue and increase until the general health gives way and fatal 
results follow. In those who have what has been styled the 
"insane neurosis," or predisposition, it may finally develop into 
some form of insanity. 

Treatment. — The first indication is to correct and control all 

those circumstances and habits which cause an undue afflux of 

blood to the internal generative organs. The 

Hygienic treatment. . . 

eating 01 improper or too highly seasoned food, 
the drinking of wines and liquors, too much or too little of 
society, all those mental and moral influences that stimulate the 
sexual appetite, tight lacing, running the sewing machine, and 
constipation, are among the avoidable causes of this disease. 
Horseback riding has induced it, and might therefore be preju- 
dicial. Exceptional cases are greatly benefited by the prohibition 
of sexual congress for the space of a week before the commence- 
ment, and a week after the cessation of the monthly flow. One 
of my patients insists that she is almost certain to suffer a severe 
attack of headache, if the act is performed in the early part of 
the night, when she is weary, instead of in the early morning 
when she has been refreshed by sleep. 

If there is a deviation of the uterus from its normal position, it 
should be replaced. If there is any obstacle to the free exit of 
the menses, whether in the form of atresia, or flexion, or of strict- 
ure of the uterine cervix, it should be removed. The general 
system should be fortified against all debilitating influences what- 
ever. In the intra-menstrual period she should be well nourished 
and sent to walk or drive in the fresh air and sunshine every day. 

Rest at the month is an important element of cure in menstrual 
headache. Neither the body nor the mind should be overtaxed at 
this period. You should be particular in this regard, else the 
patient may unwittingly upset all that you have done and can do 
for her relief. If she is occupied as a seamstress or school-teacher, 
nurse, clerk, housekeeper, or what not, she should, as far as pos- 
sible, avoid all excess of care, confinement and toil for a few days 
before, during, and immediately after the catamenia. If she 
belongs to the higher class, she should be advised to shun all 



270 LECTURES, CLINICAL AND DIDACTIC, 

excitement, to forego her fashionable appointments in society, 
parties, balls, the church, the theatre, and the opera, whenever 
this crisis comes, and to take the best possible care of herself 
until it has passed. 

The extremities should be kept warm, the head cool, the skin 
soft and flexible, the urine free, the bowels regular, the circula- 
tion equable and uniform, more especially for some days before 
the flow is due. Such patients should be protected from exposure 
to stormy and cold weather. One of the worst possible things 
for them is to get the feet wet and chilled with snow-water. 

When this disease is engrafted upon a neuralgic diathesis, elec- 
tricity properly applied is sometimes very beneficial. In some 
cases relief may be obtained by having the spine 

Electricity and magnetism. .., 

and extremities thoroughly rubbed at stated 
intervals by one who is strong and healthy. I have known a few 
cases to be cured by an itinerant "magnetizer." 

The remedies most serviceable in this disease are those which, 
because of their relation to the reproductive function, are most 

frequently indicated in menstrual derangements. 

Internal remedies. . 

Indeed, the symptoms that pertain to the lesion 
upon which this headache depends are often, although not always, 
a better guide to the choice of the remedy than the peculiar 
character of the headache itself. Pulsatilla, sepia, nux vomica, 
belladonna, ignatia, calcarea carb., platina, baryta carb., lachesis, 
chamomilla, and apis mellifica are the chief representatives of this 
class of remedies. 

If you will compare this woman's symptoms with those proper 
to sepia you will recognize their marked similarity, and agree with 
me that she should take this in preference to any other medicine. 
In another week she will be "unwell," and during that short in- 
terval she had better take a dose of sepia every evening. Let 
her report at the end of a fortnight. 

PROLAPSUS UTERI WITH RIG-HT LATERO-VERSION. 

Case. — Mrs. — complains of a series of symptoms, from which 
she says she has suffered for more than a year past. She is mar- 
ried, but has never borne any children, neither has she ' ever had 
a miscarriage. She has dragging pain in the hips and loins, and 
sometimes there is strangury, with obstinate constipation. The 



ON THE DISEASES OF WOMEN. 271 

bowels move at long intervals spontaneously, but with much effort 
and tenesmus, which at times are ineffectual. The stools are 
invariably dry, hard, and scybalous. When straining at stool, she 
sometimes " feels as if everything would be forced from her." All 
the unpleasant symptoms are increased during and for some time 
after the menstrual period. At times she experiences severe 
cramping pains in the right thigh, which come on suddenly after 
prolonged exercise upon her feet, or after standing for a consider- 
able time. The only means of relief that she has found from the 
latter paroxysms is obtained by lying down immediately upon the 
left or opposite side of the body. By keeping quiet in this posi- 
tion for a little while the cramp -like pain subsides and soon leaves 
entirely. She has not been able to lie with any degree of com- 
fort upon her right side since her ill-health began. And if she 
rolls upon that side while sleeping, the cramps in the right thigh 
will awaken her at once. She has an almost constant headache 
in the region of the temples. During and after the menses, how- 
ever, it is apt to be located in the occipital region. The flow is 
too profuse. It continues a whole week, instead of four days as 
heretofore. It is also too frequent, returning as often as every 
three weeks at the farthest. 

You have doubtless observed the relative frequency of consti- 
pation as an attendant upon the diseases of women. One of its 

most common causes is a paralysis of the rec- 
c° n gP ation from rectal tum - I have examined this patient per vagi- 

nam, and found the uterus prolapsed, and at 
the same time lying obliquely from right to left across the vagina. 
The most plausible theory of this displacement is that the descent 
and pressure of the womb against the bowel caused it to become 
paralyzed. The accumulation of faecal matter in the rectum 
forced the fundus of the uterus toward the right acetabulum, 
and latero-version was the natural and necessary consequence. 
Whether the constipation really preceded or followed the pro- 
lapsus, it would be impossible to say. Latero-version of the 
uterus always depends upon pressure applied to the side of its 
body or fundus. It is incident to the history of fibroids, ovarian 
tumors, and to tumors within the broad ligaments. When due 

to either of these diseases the organ may be 
Latero-version from an displaced either toward the right or the left 

overloaded rectum. ^ ~ 

side of the pelvis. When, however, it depends 
upon the pressure of a tumor caused b}^ impacted faeces contained 
within the rectum, the fundus will, as in the case before us, always 



272 LECTURES, CLINICAL AND DIDACTIC, 

be thrown toward the right acetabulum and the cervix toward the 
tuberosity of the left ischium. The diagnosis may be confirmed 
by the introduction of the uterine sound or probe. 

The incidental symptoms are interesting and significant. The 

cramping pains of which Mrs. complains are referable to 

pressure of the corpus uteri upon the anterior 

The cramping pains. 

branches 01 the sacral nerves. \\ hen she lies 
upon the right side, the womb falls upon those nerves, or is 
pressed by the distended rectum against them. When she turns 
upon the left side, it drops away, and the cramp ceases. When 
she walks too far, or is upon her feet for too long a time, the 
womb is more decidedly prolapsed. The nearer its approach to 
the perineum the more direct and positive the pressure of the 
rectum toward the right side of the pelvis. Straining at stool 
only increases the difficulty, and it is no marvel that she feels as 
if all the pelvic organs would be forced through the vulva. 

These cramp-like pains are very similar to those which may 
attend upon an advanced stage of labor. In presentations of the 
vertex especially, when rotation occurs suddenly and the head 
passes rapidly through the inferior pelvic strait, direct pressure 
upon the sacral nerves often causes the patient to cry out that 
her " legs are cramping." And so also in cases in which the 
womb is retroverted suddenly, as from a fall or other impulse, 
one or both the lower extremities may be violently cramped and 
even paralyzed. In this poor woman's case there is no dropsy of 
the feet and ankles, and the veins are not varicose, because the 
pressure is not applied to the vessels going to the lower extremi- 
ties. Those vessels emerge from the superior pelvis beneath 
Poupart's ligament, and are, therefore, not liable to be pressed 
upon by the uterus, excepting in its gravid state, after the fourth 
month. 

One of two causes may be sufficient to account for the implica- 
tion of the bladder in this case. The strangury might be caused 
by the displacement of the uterine cervix, or 

' The vesical symptoms. 

by pressure of the uterus against the neck of 
the bladder and the urethra. The uterine cervix is so joined with 
the inferior portion of the bladder that it can not be very decidedly 
displaced without dragging upon that organ, and giving rise to 
more or less of irritation, inflammation, and vesical tenesmus. 



ON THE DISEASES OP WOMEN. 273 

Hence it sometimes happens that the most prominent and persist- 
ent symptoms of uterine luxation are referred almost exclusively 
to the bladder. And, because they suppose that all derangements 
of the urinary function are due to renal disorder, patients not 
unfrequently consult their physician for the cure of disease of 
the kidneys, when they are really suffering from some form of 
displacement of the womb. 

Such slight degrees of prolapsus, as are incident to the men- 
strual period and to the early weeks of pregnancy, are sometimes 
the cause of frequent and painful micturition. These sufferings 
are, however, relieved spontaneously — by the escape of the mens- 
es and the subsidence of the monthly hyperemia in the one case, 
and by the final ascent of the uterus above the superior strait in 
the other. In chronic prolapsus all these symptoms are made to 
vanish, at least temporarily, by lifting the womb into its proper 
position. 

This case illustrates the possibility of uterine displacements 
disconnected with abortion or with labor at term. The frequent 
return of menstruation, and the excess of the flow, indicate a pri- 
mary disorder of this very important function. 

Treatment. — There are two reasons why this woman is not well. 
The first is, that her rectum is paralyzed ; the 

Leading indications. 

second, that she menstruates too freely and fre- 
quently. All the symptoms that have the least significance may 
be referred to one of these two causes. 

This is the most common form of constipation in females. If 
the muscular coat of the rectum has lost its tonicity through 

neglect of the patient to attend to the calls of 
P adon remedy the constI " nature, or to go to stool regularly every day, 

this bad habit should be corrected. Enemata 
containing olive oil, or castor oil, may be given for temporary 
relief, with the view of softening and removing the impacted 
fseces. Laxative food is of more service in constipation depend- 
ing upon causes which affect the upper portion of the intestine. 
Some of these patients with paralysis of the rectum might eat 
brown bread, oat meal, figs, prunes, or baked apples until dooms- 
day without the least benefit. 

If the uterus is prolapsed, or so displaced as to press directly 
against the rectum, that pressure must be removed, or the con- 



274 LECTURES, CLINICAL AND DIDACTIC, 

stipation can not be cured. And since these causes act and 
react, the uterine deviation may depend upon 
reS^rtteute/us 01 " 1 " - ^he -^ ac ^ °^ resiliency in the rectum, the pres- 
ence of fsecal matter within the gut, or upon 
straining at stool. Pessaries are contra-indicated in case of 
uterine displacement with profuse and too frequent menstruation. 

The most ordinary remedy for this variety of constipation, 
with its incidental uterine displacement, are alumina, mix vom- 
ica,, natrum mur., plumbum, opium, belladonna, sulphur, zincum, 
and lycopodium. 

Among those which are in best repute for the cure of too fre- 
quent and copious menstruation you will find calcarea carb., 
china, phosphoric acid, cantharis, zincum met., spongia, sulphur, 
creasotum, and magnesia carbonica. 

This patient will take nux vomica 3d at night, and calcarea 
carb. 3d in the morning, one dose of each daily. She must keep 
off her feet as much as possible, particularly at the catamenial 
season. 

ACUTE CERVICAL METRITIS. 

Case. — Mrs. — : — , aged 35, the mother of three children, the 
youngest of which is six years old, relates the following story : 
Eight days ago, at the proper time, the menses made their appear- 
ance without any unusual symptoms. On the same morning she 
commenced a five days' job of work upon the sewing machine. 
At the close of the first day's labor the flow ceased for some 
hours, and then, after a foot-bath and a night's rest, it returned. 
On the third day there was another intermission in the menstrual 
discharge, and on the fourth day it ceased entirely — two days 
sooner than usual. 

She now conrplains of headache, with slight vertigo, the face 
is flushed, the pupils are somewhat dilated, noise worries her, and 
she can not bear the light. There are cutting, darting pains in 
the upper portion of the thighs and across the hips. These pains 
are worse on motion and while standing upon the feet. She also 
has a burning, bearing-down pain within the pelvis, some stran- 
gury, and great discomfort. She is very nervous and apprehensive. 

The " touch" reveals the os uteri patulous, the cervix swollen, 
hot, dry, and exquisitely tender. She can not bear the least pres- 
sure upon it. The womb lies very low in the pelvis, so much so 
that when she stands upon her feet it rests upon the perineum. 

Examination with the speculum shows the tumefied and tender 



ON THE DISEASES OF WOMEN. 275 

cervix to be congested and more than twice as large as natural, 
but there are no signs of abrasion, neither of ulceration. The 
epithelium covering its vaginal portion is intact, and there is no 
unnatural discharge from the external os uteri. 

This is a case of acute inflammation of the neck of the womb. 

Writers describe two varieties of cervicitis — one in which the 

substance, or parenclryma of the uterine cervix 

Varieties of. . . 

is the seat ot the inflammation (cervical metri- 
tis), or areolar hyperplasia (Thomas) ; another in which the 
inflammation is limited to the mucous membrane that covers the 
vaginal portion and lines its canal (cervical endo-metritis). These 
diseases are so frequent and troublesome that you will need to 
study then clinical history most carefully. 

Cervical metritis is very rare in those women who have not 

given birth to one or more children, either prematurely or at term. 

Indeed the most powerful predisponent of this 

Rare in nulliparae. . . _ ... 

disease is found in the changes which are inci- 
dent to the uterine cervix during the middle and later months of 
gestation. The virgin cervix is firm and fibrous, almost cartilag- 
inous in texture. Its vascularity is not at all pronounced, its dil- 
atability is scarcely sufficient to permit the ready exit of the 
menses. But the modifications which it undergoes during preg- 
nancy change the consistence of its tissues, not temporarily, but, 
in a sense, permanently. The contraction and involution which 
follow delivery do not restore the unyielding nature which is 
proper to the virginal cervix, and thenceforth we find it liable to 
diseases from which it Avas exempt before. 

One of the most frequent of these affections is acute cervical 
metritis. And all of its exciting causes produce a more decided 

and damaging effect if they are applied at or 
pred^po^en? 13 ' cyde a about the time of the menstrual return. It is 

possible that this woman might not have expe- 
rienced &tlj ill consequences from the same kind of exercise had it 
been taken at another time. But, she " did not think," — a very 
common infirmity with patients as well as with their physicians — 
and therefore, she set to work the very day the flow began, intend- 
ing to persevere with it during the kt period." 

Much has been said and written of the sewing-machine as a 
cause of uterine disease. I apprehend that it is the abuse, instead 



276 LECTURES, CLINICAL AND DIDACTIC, 

of the proper use, of the machine that works the mischief in those 

who run it. The trouble is that, with most 

sewing machines and housekeepers, it offers such a ready and expe- 

utenne diseases. -"- 7 J L 

ditious means of doing the family sewing that 
they are tempted to postpone this labor until it has accumulated 
for weeks, and perhaps even for months. Then they go to work 
for days and nights consecutively, in order to despatch it, and to 
" get it out of the way." The instrument itself may be as inno- 
cent as the piano. It is this habit of playing upon it, or rather 
of working with it, continuously for hours and days together, 
that does the harm. If the same work were properly distributed, 
as our wives and daughters "practice " upon the piano — not as 
a business, but as a recreation and diversion, the result would 
doubtless be very different. In the case of those women, how- 
ever, who are obliged to sit at the sewing-machine from morning 
until night each day in the week, in order to obtain a livelihood, 
it is almost impossible for them to escape certain functional and 
organic diseases of the womb. 

Whatever tends to wound, bruise, or irritate the neck of this 
organ may, in those who are predisposed to it, give rise to cervi- 
cal metritis. Too violent exercise, as horseback 
m 5;^L es of acute cervical riding, or riding* in a rough carriage or car ; 

metritis. &" O o © ' 

misplaced, or badly-fitting pessaries ; too forci- 
ble and excessive coitus ; prolapsus, and the various flexions of 
the uterus ; standing for too long a time upon the feet, as in the 
case of female clerks in our shops and stores, and of ladies at 
fashionable parties ; a sudden arrest of the menstrual flow ; and 
the extension of the inflammation in cervical endo-metritis from 
the lining membrane of the uterine cervix to its parenchymatous 
structure, are among the more common exciting causes of this 
disease. 

You will readily understand how it is possible for either of these 
causes to develop this form of metritis by converting the physio- 
logical injection of its structures, which is nec- 
res^uks 6 ° f operatIon and essary to their nutrition and also to the men- 
strual function, into a pathological congestion 
thereof. A local arrest of the circulation, a temporary sluggish- 
ness, or stasis of blood in its loose, connective, dilatable tissue, 
represents the first step in the inflammatory process. What the 



ON THE DISEASES OF WOMEN. 277 

result of this engorgement will be we can not say beforehand. If 
the cause is not removed and the case properly treated, the cervix 
may become the seat of chronic inflammation, hypertrophy, indu- 
ration, and possibly of scirrhous deposit. 

Acute cervical metritis is more likely to be confounded with cer- 
vical endo-metritis than with any other disease. In the former, 
the neck of the womb is swollen and tender, 

Differential diagnosis. 

not only to a light touch, but also to pressure 
upon it from within the vagina, and through the rectum ; there is 
no abrasion and no ulceration, no appearance of hypertrophied 
villi (so often mistaken for granular ulceration) and no leucor- 
rhceal discharge. The constitutional symptoms are such as attend 
upon the more severe forms of local congestion and inflammation 
in other parts of the body. There is almost always pain in the 
head, photophobia, a flushed face, and such nervous symptoms as 
those of which this patient complains. 

Fortunately the organic changes in the cervix, which are the 
sequelae of acute cervical metritis, develop so slowly that prompt 

and proper treatment may prevent the disease 

Prognosis. » , . -. T , 

irom becoming chronic. In most cases, how- 
ever, these changes take place insidiously and in a latent manner, 
so that the acute stage will have passed before the physician is 
consulted. Doubtless the frequent return of the menses serves to 
perpetuate the liability of the neck of the womb, which has once 
been inflamed, to repeated attacks, that may finally end in estab- 
lishing the chronic form of the disease in it. In those women in 
whom the cervix is unusually long, as well as in those who are of 
a relaxed fibre, cervical metritis is very apt to become chronic and 
intractable. The same is true if the disease occurs in women of 
a decidedly bilious temperament, and who may be suffering from 
old hepatic disorders. Chronic affections of the rectum, as pro- 
lapsus and haemorrhoids, sometimes retard or prevent the cure of 
a case of cervical metritis. 

Treatment. — The increased suffering which this woman experi- 
ences when she is upon her feet, suggests that she should not be 

allowed to walk about. The horizontal posture 

Postural treatment. 'in • -i-ii >i 

is the first thing you should prescribe lor simi- 
lar cases. You can not expect to cure them readily if the posi- 
tion of the patient's body facilitates and necessitates a determi- 



278 LECTURES. CLINICAL AND DIDACTIC, 

nation of blood to the inflamed part. Especially should these 
patients be counseled to keep to the bed or sofa during the men- 
strual period, and for some days thereafter. They should also 
avoid all those emotional influences which might, directly or indi- 
rectly, excite the sexual system. The bladder should be emptied 
regularly, and the bowels not permitted to become torpid and in- 
active, or otherwise the infra-pelvic circulation might be so 
deranged as to prevent the best chosen remedies from having their 
desired effect. 

If, in a given case, there is reason to believe that any of the 

causes already named has occasioned the attack, that cause must 

be removed. And you should act promptly. 

Remove the cause. . _ . . _ n 

Learn the source of the mischief and remove it 
as soon as possible, else the most proper and appropriate time for 
curing the case, or at least for preventing it from developing into 
the chronic form of the disease, will have passed before you have 
accomplished anything. 

As the result of an abundant experience, I am persuaded that 
in these cases of engorgement of the cervix uteri, with incipient 

inflammation of its deeper-seated tissues, " pre- 
^Prevention better than ven ti n is better than cure." Hygiene should 

go hand in hand with Therapeutics. It would 
not be sufficient to give this woman belladonna, or any other rem- 
edy, and dismiss her without specific instructions concerning her 
habits of life, of exercise, and exposure. It is just here that our 
knowledge of special physiology and of special pathology will 
render us the most important aid. It may fail to suggest the rem- 
edy for the symptoms complained of, but it will not fail to suggest 
what, in such a case as this, is vastly more important. 

It might involve a species of suicide for this patient to persist 
in running the sewing machine. She should not ride or walk very 

far or frequently. A journey from Chicago to 

New York, before her symptoms are relieved 
and the next menstrual period safely passed, might render her an 
invalid for months or even for years. And so also of croquet, of 
ironing, sweeping, or prolonged standing upon the feet, whether 
for pleasure at a party, or for profit in a store or in school. Any 
menstrual irregularity should be remedied. Sexual congress should 
be prohibited. Pessaries and every species of artificial support, 



ON THE DISEASES OF WOMEN. 279 

whether within the vagina or around the body, are positively and 
decidedly mischievous in this class of cases. The same is true of 
the use of cold and astringent injections thrown into the vagina, 
and of most of the lotions and ointments that are applied in case 
of haemorrhoids. 

If you can properly attribute the attack to traumatic injury, 

there will be no harm in prescribing a vaginal injection, consisting 

of the tincture of arnica, glycerine, and tepid 

Local measures. # x 

water. In case she has haemorrhoids, with 
venous discoloration of the vagina, or a varicose condition of the 
veins of the lower extremities, it is best to substitute hamamelis 
for the arnica. Simple glycerine and water, one part of the former 
to five of the latter, will sometimes allay the burning heat and 
pain within the pelvis. I have occasionally witnessed the best 
effects from Dr. Sims' method of applying pure glycerine directly 
to and about the cervix by means of a cotton or sponge tampon 
which is saturated with it. In one of my cases it certainly brought 
away half a teacupful of serum with which the swollen and pen- 
dulous cervix had previously been engorged. It may be possible 
by some such simple and harmless expedient to prevent what 
might otherwise develop into chronic cervical metritis. 

The internal treatment should be regulated by the obvious 
symptoms peculiar to the individual case for the cure of which you 

are consulted. This woman will take of bella- 

Prescription. 

donna dd, a dose every three hours. When her 
symptoms are somewhat improved, it may be repeated once in six 
hours. Let her come again next week. 



280 LECTURES, CLINICAL AND DIDACTIC, 



LECTURE XVII. 

hysteria. 

Gentlemen : 

Although I have already given you a clinical outline of hysteria,* 
the subject is by no means exhausted. Indeed, there is enough 
in this single topic for a whole course of lectures. For this dis- 
order modifies and complicates almost all the diseases to which 
women are liable. 

Case. — At 7 P. M. of yesterday, I was hurriedly summoned to 

the relief of Mrs. , aged 20 years, three months advanced in 

her first pregnancy, who was seized while at the tea-table with 
an unnatural staring and blindness, followed by a species of fit, 
which greatly alarmed the husband and family. I found her lying 
in an unconscious state upon the floor of the dining room. The 
eyes were staring widely and wildly, and at times the eye-balls 
were rolled upwards as far as possible. The pupils appeared nat- 
ural, excepting at intervals of from five to ten minutes, when a 
general spasm of all the muscles of the extremities ensued ; they 
would suddenly increase in size and become very large. With the 
approach of this symptom the face would flush, and she would roll 
from her left to her right side. The arms were thrown wildly 
about, and during the fit it was almost impossible so to hold her 
as to prevent her from doing herself a personal injury. Each 
paroxysm ended with sobbing and an attempt to articulate. The 
pulse was 80 and quite regular. From her manner it appeared 
that she was dreaming and talking, or holding intercourse with 
some person not present in the room, or at least not visible to the 
attendants. While the fit was on, the facial muscles twitched 
violently, but there was no frothing at the mouth, or purplish dis- 
coloration of the face. The carmine hue which came and went, 
however, caused her to appear very beautiful. 

I ordered a plentiful supply of fresh air, the clothing to be 
loosened about the throat and waist, and belladonna 3rd to be given 

* See pages 87 and 107 of this volume. 



ON THE DISEASES OF WOMEN. 281 

her (very slowly) once in twenty minutes until the fits ceased, 
and after that every half-hour until I called again. 

9 P. M. She had only one paroxysm after taking the first dose 
of the medicine, but the emotional outbreaks had become more 
marked. She would exclaim, "Oh, so dark!" then talk inco- 
herently, and finally cry and sob for some moments most pitifully. 
After a little it became evident through her speech that she was 
in communication with her mother, who, it was said, had died five 
years before. This last symptom was looked upon as supernatu- 
ral, and alarmed the bystanders exceedingly. They declared it 
to be a premonition, and unfailing sign of the speedy departure of 
the patient for the land of spirits ; but the husband told me that 
she had frequently had similar attacks, and that in all of them she 
had shown this same symptom. 

By my advice she was carried from the sofa to her room, placed 
quietly in bed, the half dozen voluntary nurses discharged, and 
she left alone with her husband for the night. This morning he 
called to report that his wife had slept soundly for some hours, 
and now appeared quite well, although a little weak.* 

Hysterical attacks usually bear some relation to the menstrual 
period. A woman is ill with a protracted and debilitating disease, 

as for example pneumonia, or typhoid fever. 
straai st mofimen the men ~ P erna P s sne nas escaped one or more " periods." 

But the return of the monthly cycle is shown 
in a peculiar aggravation of the coincident nervous symptoms. In 
lieu of the proper flow, she becomes unusually wakeful, restless, 
fitful, or disheartened. Nothing pleases or satisfies her. Her 
nurse is charged with neglect, she thinks that her friends have 
become heartless, or that her physician has lost interest in her 
case. In consequence her family take alarm, and unless he under- 
stands his business very thoroughly, the doctor may be led to make 
an unfavorable prognosis. The perturbation reacts upon the 
patient, who is very impressible, and the hysterical flame grows by 
what it feeds upon. The neighbors clamor for " counsel," or for 
" a change of treatment," and are permitted to have their way. 
The physician who is called in may or may not have tact enough 
to recognize the real condition of the patient. If he can separate 
the hysterical element, can date the exacerbation from the recur- 
rence of the month, can proceed quietly to the cure of the origi- 

* Although similar attacks occurred at the fourth, fifth and sixth months, this patient 
reached term without any further mishap, and was finally delivered of a healthy ten- 
pound child. She had no convulsions in child-bed. 



282 LECTURES, CLINICAL AND DIDACTIC, 

nal idiopathic disease, all may yet be well. Otherwise she may 
continue to grow worse instead of better. The issue may depend 
entirely upon his skill in diagnosis. The distinctive feature of 
hysteria will sometimes enable }^ou to decide whether those women 
who are ill with acute disease are really in so dangerous a condi- 
tion as they appear to be. 

Although child-bearing, if it be not too frequent or exhaustive, 
is a good general prophylactic of hysteria: and although preg- 
nancy may . exempt from an attack of it : 
^Hysteria during gesta- t ] ie opposite effect may follow conception 
and the arrest of the menses. When, as in 
this case, the disease comes in distinct paroxysms during preg- 
nancy, the fits are more likely to recur at or about the time 
the patient would have menstruated. This fact explains the 
liability of their developing into a form of ante-partum convul- 
sions, of which I have already spoken ; and also the increased 
risk from abortion, which, for physiological reasons, is more immi- 
nent at the month than at other times. 

Attacks of hysteria occurring as a concomitant of other dis- 
eases, or as a contingent of pregnancy and lactation, may safely 
be referred to some emotional excitant. The 

Emotional causes of. - . . . 

previous disease, or condition, has caused such 
debility and prostration, as powerfully to predispose to nervous 
derangement, and the patient is an easy prey to the depressing 
emotions. She may be borne down by influences which, under 
different circumstances and at other times would have had little 
or no effect upon her. And these circumstances include a list of 
avoidable causes which in themselves are so small and apparently 
insignificant as frequently to escape notice. We are very apt to 
forget — if indeed we ever knew — that it is possible for psychical 
causes alone to derange the blood-making process, and to poison 

the very fountain of life. If violent mental 

Possible effects of. . ■ . , 

emotions will prevent the blood of a healthy 
person from coagulating when it is withdrawn from the body, 
they certainly are capable of destroying life, as by a slow poison, 
when they are brought to bear upon an organism in which the 
blood is already impaired and impoverished to the last degree by 
previous disease. I apprehend that thousands of patients have 
died when otherwise they would surely have recovered, because 



ON THE DISEASES OF WOMEN. 283 

at a most unfortunate moment they were seized by fear and appre- 
hension, by grief or fright, or jealousy, chagrin, disappointment, 
or some form of mental depression and agitation, from the fatal 
effects of which they could not be rallied. In illustration of this 
view I may mention the following 

Case. — I was called from my hotel at 2 A.M., December 6, 
1861, to visit a most estimable lady who was said to be dying of 
typhoid fever. She had been ill for five weeks under the charge 
of another physician, and had had a morbid fear of death from 
the onset of the fever. The doctor and the counsel had left her 
at 8 P.M., of the previous evening, after having told the family 
that she could not possibly survive the night. My friend, the 
messenger, insisted upon my visiting her and giving her something 
" to make her die easily," as much on his own wife's account and 
that of others in the house, as from motives of humanity. Her 
clergyman had visited her soon after the doctors left, and her 
friends had bidden her a final adieu. She then became apparently 
unconscious, and passed into a peculiar mental state, in which the 
nurse told me she had a vision of her mother, who had died some 
fifteen years before. She then began to exclaim, over and over 
again, " Oh, my blessed mother !" which phrase she had continued 
to repeat so that everyone in the house could hear it. Sometimes 
it was spoken distinctly, and again she mumbled it, so that one 
could not understand what she was saying ; but it was always in 
the same dreary monotone, which was anything but cheerful in 
the middle of the night, and under such painful circumstances. 

I asked the nurse if the patient could see ? She assured me 
that for several hours she had been entirely blind. Could she 
swallow ? No. Between her exclamations, I thought I detected 
the woman looking at me askant and in a peculiar way. I 
attempted gently to part the eyelids, in order to look at the pupil 
of the eye, but tney were so suddenly and decidedly closed as to 
betray a species of volition somewhat inconsistent with the 
alleged danger. The pulse was 115, distinct but excited. I 
called for some water and a spoon. When I separated the lips 
to put a little of the water into her mouth there was a similar 
resistance. The mouth was closed firmly, almost, "with an 
audible snap," as the surgeons say of the sudden reduction of 
certain dislocations. A little tact enabled me to get the water 
into her throat, and to compel her to swallow it. I was impressed 
with the idea that she was really in a semi-conscious state, and 
that some of her symptoms arose from a morbid desire to excite 
sympathy, or, briefly, that they were hysterical. 

A dose of ignatia in the third decimal attenuation was given 
her immediately, and the nurse was directed to give another in 



284 LECTURES, CLINICAL AND DIDACTIC, 

half an hour, and a third also in case she did not become quiet 
and fall asleep. The room was to be cleared of all the friends 
who had come to witness her death ; she was to be "let alone 
severely," and no one, excepting the nurse, permitted to remain 
with her. The husband and relatives were assured that the dan- 
ger was more imaginary than real, and that if she could sleep and 
be properly nourished, she would almost certainly recover. 

She soon stopped the dreary talk about her mother, became 
calm and fell into a quiet sleep, from which she wakened at short 
intervals. In the morning she was better. She took no other 

o 

medicine, was well fed, and her funeral was " indefinitely post- 
poned." Eleven years have elapsed, and she is still alive. 

Now, gentlemen, you shall decide whether, if some one had 

not recognized the real condition of things in this case, and 

changed it very decidedly, the circumstances 

A practical inference. . . 

which surrounded that woman in her weak 
condition, might not have overwhelmed her and caused her 
death. 

The well-known tendency of hysteria to imitate other diseases 
has in it a tinge of deceit. It may simulate almost any affection 

so closely, as to puzzle the best diagnostician, 
Wena atical nature ° f an( ^ ^° disappoint the most skillful practitioner. 

Or it may complicate other maladies by coun- 
feiting single symptoms. Women of an hysterical constitution 
seldom pass through the different stages of an acute inflammation, 
or fever, without some peculiar experiences and revelations which 
are totally foreign to the special pathology of the disease in ques- 
tion. These complications m&j be classed as hysterical. 

In such cases you will observe that those symptoms which are 
incidental and least important, are liable to be incongruous and 

very much exaggerated. If, for example, such 

Suspicious symptoms. . .,,.,. .-,-, 

a patient has pneumonia, the physical signs will 
not be such as should correspond to her complaints of pain and 
suffering, and to the assumed character of the cough. The sputa 
may tell one story and her tongue another. Or, if she has dysen- 
tery, there may be a similar lack of congruity between the symptoms 
of which she complains, and the visible, objective phenomena. 
Taking the impress of this peculiar idiosyncrasy, or dyscrasia, the 
nervous symptoms, and especially the delirium of such a subject, 
in typhoid, or puerperal fever, will be very greatly modified. In 



ON THE DISEASES OF WOMEN. 285 

each case the symptoms which are proper to the disease will be 
supplemented by others which are spurious, and also by a more 
or less decided uproar among the physical functions. And thus 
it may happen that your wits will sometimes be taxed to decide 
which is fact and which fiction. The spurious, contingent and 
irrelevant symptoms are the most noisy and clamorous, but not 
most significant and perilous. The complaint that is made is not 
always a reliable criterion of suffering and danger. 

The hysterical subject, whether male or female, is addicted to 

hyperbole. The symptoms of which I have spoken resemble an 

over-anxious witness at court, — they testify to 

Hysterical exaggeration. . 

too much. J- hey are actors who " mouth their 
part." This tendency to exaggeration is a suspicious element 
which will bear watching. It is so closely related to the lying 
propensity as almost certainly to betray its true character. You 
will require a large measure of tact and common sense for its 
detection. 

The gossip takes the scent of an ill-assorted marriage, and of 
marital and social infelicities, with the instinct of a hound and 

the tact of a savage. In his diagnosis the 

doctor is perhaps more easily deceived and 
decoyed. He is generally less shrewd and less skillful in his dis- 
crimination. It may not have occurred to him that symptoms, 
like individuals, are sometimes married without being mated. As 
the fruit of large experience and observation, I am persuaded that 
one great and essential difference between physicians consists in 
their varied ability to separate, to seize upon, to interpret and to 
remedy those symptoms which are truthful, characteristic and 
legitimate, to the exclusion of such as are of secondary import- 
ance, fictitious, accidental and irrelevant. 

There is a species of malingering which is a curious feature in 

some cases of hysteria, a marked example of 

A species of malingering. . . 

which came under my own observation some 
years ago. 

Case. — A young lady of sixteen fell ill with the usual symp- 
toms of spinal irritation. She soon complained of a loss of power 
to move the left arm, then the right one, and successively the 
lower limbs also. For eight long years the bed-ridden subject of 
this affliction could neither stand nor feed herself. The sympa- 



Incongruous symptoms. 



286 LECTURES, CLINICAL AND DIDACTIC, 

thies of the best women of the neighborhood overflowed in deeds 
of kindness and of charity to the poor sufferer. Finally the nurse 
observed that when she was left alone the patient would some- 
times get possession of articles that were distant, from her bed, 
and this without the aid of a third party. By and by a plan was 
arranged to discover if she really did leave her bed in the absence 
of others from her chamber. She was notified that for a short 
time she would be left alone in the house. They watched her, 
and ten minutes after the alleged departure of the family she was 
seen to rise and walk off as well as anybody. The spell was 
broken and she recovered immediately. 

If the consequences of this species of fraud were limited to the 

friends and relatives, who are usually victimized, they would be 

less troublesome and more easily remedied. 

th! e pa3ent ry effects upon But tne worst 0I> & is tnat tne patient may also 
deceive herself. The sympathy and anxiety of 
her friends may cause their judgment to be too easily influenced ; 
and the mental and physical weakness of the patient may finally 
lead her to believe that her symptoms are real, and not assumed, 
as she knew them to be at the beginning. For it is possible that 
a sick person may lie to himself, or herself, and not be able to 
detect it. In hysterics self-deception is frequently compounded 
with the intent to impose upon others. And you will learn from 
experience that it is much easier to correct the impressions of 
those who surround the patient, than it is to dislodge these reflex 
ideas from the mind of the woman herself. 

In diagnosticating the various forms and complications of 
hysteria there are a few signs which almost deserve to be classed 
as pathognomonic. These are (1) that, as a 
of L hys d te n rfa Characteristics ru ^ e ' tne disease is limited to females, and in 
them to the period usually termed " menstrual 
life," id est, between the ages of fourteen and forty-five ; (2) that, 
while it may simulate, succeed, or complicate any other disease, 
its symptoms are much exaggerated, irregular, and out of propor- 
tion with those which properly belong to that disease, whatever 
it may be ; (3) that, in general, however great the disorder 
among the functions, the pulse is not changed, and the appetite is 
more frequently excessive than deficient. 

Diagnosis. — The cardiac affections with which hysterical dis- 
orders are sometimes confounded are valvular lesions, dropsy, and 
alleged displacement of the heart. 



ON THE DISEASES OF WOMEN. 287 

"When they do exist, the symptoms of valvular disease of the 
heart in hysterical subjects are almost invari- 
theh°™rt alvular disease ° f abl 3 7 associated with chloro-anaemia. The 
blood is impoverished. The rhythm of the 
heart's action is disturbed, and there is fluttering and precordial 
oppression, palpitation and an exaggerated impulse against the 
thoracic parietes. In chronic cases there may be dropsy of the 
feet and of the face. 

Physical exploration will enable you to decide between real and 
spurious lesions of the valves. In bona fide disease of the valves, 
either the first or the second sound of the heart is impaired in its 
quality, or its place is supplied by an abnormal murmur. If the 
first of these is implicated or superseded, we know that the 
auriculo-ventricular valves are diseased ; if the second sound is 
changed, that the semilunar valves are the seat of the difficulty. 
In hysterical affections which counterfeit this form of endo-cardial 
lesion both the cardiac sounds are normal. With the first sound of 
the heart, however, we note the soft bellows murmur of anaemia. 

This adventitious sound arises from a change in the quality of 
the blood, as well as from deranged innervation of the heart itself. 
Both sets of valves perform their function properly, and although 
there is palpitation and dyspnoea, yet there is little or no change 
in the pulse. The dropsy of the feet and of the face, when it 
does exist, are of hemic origin. All the physical signs of valvu- 
lar disease are lacking. There is neither patency nor constriction 
of the orifices, and no insufficiency of the valves that could pos- 
sibly give rise either to obstruction or regurgitation. 

Case. — Miss , aged 22, came to this city from Vermont in 

order to consult me for the relief of precordial symptoms which 
had troubled her for three years. Her disease had been pro- 
nounced a valvular affection of the heart, and she had already 
been treated by three physicians. She complained of languor, 
lassitude, and anorexia, with disgust for meat of all kinds, of 
which she had eaten none for more than two years. The bowels 
were habitually constipated. The slightest exertion caused fatigue 
and a distressing dyspnoea. The recumbent posture was most agree- 
able ; indeed, she could rest in no other. There was almost com- 
plete insomnia. When she did sleep she was not refreshed, but 
awakened with renewed apprehension. The complexion was pale 
and chlorotic, the ale nasi and lips colorless. The pulse 82. weak 
and compressible, but regular. There was occasional palpitation 



288 LECTURES, CLINICAL AND DIDACTIC, 

and painful oppression of the left chest, particularly after exercise 
and when lying with the head low. 

Auscultation revealed the bellows murmur accompanying the 
first sound of the heart, and I felt confident that what had been 
mistaken for organic disease of the valves was really chargeable 
to the deteriorated quality of the blood. She was treated for the 
chloro-ansemia, and the cardiac symptoms soon vanished. In three 
months she was quite well, and has continued so during an inter- 
val of six years. 

Women who are supposed to have dropsy of the heart some- 
times complain of great difficulty of breathing after exercise, of 
orthopncea, of cramping, cutting pains in the 

From dropsy of the heart. . . 

cardiac region, of stifling sensations, of a stop- 
page of the heart's action, or of a feeling as if it had suddenly 
turned topsy-turvy, of gurgling, and even as if the heart were 
pulsating in a collection of water. And yet all these symptoms 
may be found to represent a spurious affection. In diagnosticat- 
ing true from false hydropericardium you should remember that, 
in the adult subject, the former is almost always a sequel of rheu- 
matic pericarditis. This is not true of the hysterical disorder, 
which, in its objective symptoms only, resembles dropsy of the 
heart. In real hydropericardium the heart-sounds, the respiratory 
murmur, and the vocal resonance, as well as the pulse, are always 
implicated. The nutritive function is impaired, the blood is thin 
and impoverished, there is a tendency to dropsy of the joints and 
lower extremities, as well as to general anasarca. But in the 
spurious variety the very opposite is true, and no such concomi- 
tants are present. 

Hydropericardium has no necessary specific or setiological rela- 
tion to menstruation and its several disorders. It is a dangerous 
disease, more especially if the patient is of a dropsical diathesis, 
or if she has had some previous difficulty with the heart, the 
larger blood vessels, or the lungs. Hysterical derangements are 
intimately connected with ovulation, both with respect to their 
commencement at puberty, the recurrence of the attack, the 
aggravation of the symptoms at the " period," the modification 
induced by pregnancy and lactation, and also their cessation at 
the climacteric. They are always more alarming than serious. 

It is not an uncommon occurrence for a hysterical patient to 
complain that her heart is displaced ! And this symptom may 



ON THE DISEASES OF WOMEN. 289 

annoy her exceedingly. The mal-location may appear to her to 

be either transient or permanent. Emotional 

Alleged displacement of i n fl uence s "brings her heart into her mouth." 

the heart. o 

She suffers from violent palpitation, and some- , 
times from abnormal pulsations in different parts of the body. Her 
general appearance is healthy, her habit is plethoric, and her looks 
belie her sensations. The anaemic murmur is sometimes so dis- 
tinctly heard by such a patient as to induce the belief that her 
heart is actually dislocated. As a rule you will perhaps encoun- 
ter more numerous cases of this kind among healthy, bouncing 
Irish girls, and the fat, lazy drones of fashionable society than 
elsewhere. I need not tell you that the complaint has no founda- 
tion in fact. 

The hysterical cough is a species of nondescript. Its negative 

peculiarities are by far the more prominent. Physical exploration 

will not help you to judge of its cause or sig- 

The hysterical cough. . 

nmcance. JNone 01 the symptoms give evidence 
of irritating matters lodging in the respiratory passages, or of any 
•lesion of the pulmonary organs. The cough is purely sympathetic, 
reflex in its origin, and serious only through its persistency. 

It is likely to be excited and aggravated by the most trivial cir- 
cumstance, more especially by mental shock and emotional influ- 
ences. In the case of one of my patients the 

Case. 

slightest movement, the opening or closing of a 
door, however noiselessly, the footstep of an attendant, or the 
least current of air, no matter if she were sleeping, invariably 
precipitated a fit of coughing. There was some tenderness over 
the upper cervical vertebrae. She was cured wiih a few doses of 
silicea 6th. 

Your tact will be called into exercise in order to dispel a set- 
tled conviction that such patients are consumptive. The same 
imitative propensity which sometimes causes a 
toSi a di n seal S e — frompec " number of women to be seized with listeria in 
a room where another is in a fit, leads those of 
an hysterical constitution to simulate a cough which does not 
depend upon any pectoral lesion whatever, but which may result 
in harmful consequences unless recognized and properly treated. 

This cough is apt to be harsh, dry, barking, and paroxysmal. 
It alarms those who hear it more than the patient herself. In 
19 



290 



LECTURES, CLINICAL AND DIDACTIC, 



proportion to the frequency and severity of the paroxysm, the 
affection is sometimes complicated with spasm 
lkStS? lications * nd pecu ~ of the diaphragm, and the singultus annoys the 
patient while it amuses her. This admixture 
of symptoms, especially in the early stages of the disorder, causes 
the proper hysterical symptoms to crop out more prominently. 
She either laughs, sobs, chokes, or cries immoderately. If the 
diaphragm is very much affected, there will be more or less 
orthopnoea. The pulse is but slightly, if at all, accelerated, and 
the appetite and digestive function are intact. In case of coinci- 
dent amenorrhoea, there may be vicarious menstruation in the 
form of haemoptysis. 

You would diagnosticate the hysterical from other forms of 

asthma by its manifest connection with uterine and menstrual 

disorders. The attack generally precedes the 

From asthma. •,,.. -.. ,. -., . 

monthly crisis and is relieved by it. lhe tho- 
rax feels tight and restricted. The paroxysm is aggravated by 
emotional causes, more especially by such as excite the passions 
and tend to pervert the moral nature. Even during the suffo- 
cative fit one may sometimes detect the hysterical fondness for 
deception. The regularity of the attack — when it returns every 
month — will confirm the diagnosis. 

The hysterical aphonia is not very difficult of diagnosis. Apho- 
nia is never an idiopathic affection. It may arise from laryngitis 
directly or indirectly, in which case the local 
and constitutional symptoms would aid you in 
making out its differential diagnosis from the hysterical aphonia. 
We may classify the prominent symptoms of the two affections 
thus : 



Hysterical aphonia 



APHONIA FROM LARYNGITIS. 

1. Febrile disorder ; a quick pulse. 

2. The loss of voice is sudden and com- 
plete in proportion to the extent and 
violence of the inflammation. The 
aphonia disappears slowly, and is 
prone to become chronic. 

3. There is more or less cough and expec- 
toration, which are paroxysmal, and 
vary in character in different stages of 
the disease. 



HYSTERICAL APHONIA. 

1. Absence of fever ; the pulse is nor- 
mal. 

2. The aphonia comes and goes abruptly, 
and without leaving any local lesion 
or sequel behind it. The relief is 
sudden and perfect. 



3. Cough is a rare concomitant of this 
form of the complaint. There is no 
necessary or characteristic expectora- 
tion. 



ON THE DISEASES OF WOMEN. 



291 



APHONIA FROM LARYNGITIS. 

4. The inspiration is noisy, harsh and 
stridulous. At an early period it may 
be croupal, but later it is less labored 
and softer. 

5. The dyspnoea is attended by an anx- 
ious expression of countenance. She 
may have fits of suffocation. 

6. There is complaint of angina. The 
fauces and uvula are congested and 
inflamed, with tickling, raw or burn- 
ing sensations, which extend into the 
larynx and trachea. 

7. Pain referred to the pomum Adami. 
These pains are sticking and lanci- 
nating in character. 

• 

8. The anterior surface of the neck is 
sore and tender to the touch, and she 
will not permit one to handle it 
roughly. 

9. In the acute form the aphonia usually 
results from taking cold. 



10. Has no necessary 
irritation. 



relation to spinal 



In the chronic form it may be due to 
over-fatigue and exercise of the vocal 
organs, or from causes which occa- 
sion a low grade of inflammation 
with hypertrophy or ulceration of the 
laryngeal mucous membrane. 



HYSTERICAL APHONIA. 

4. The inspiration is heaving, sighing, 
and spasmodic, the rale being moist 
and softened in its tone. 



The features are calm and inexpress- 
ive. She is more liable to syncope 
than to suffocation. 

There is a complete absence of faucial 
and tracheal inflammation and suffer- 
ing. 



7. There is no complaint in or about the 
larynx. 



8. Globus hystericus, with clutching at 
the throat. She tears away the cloth- 
ing from about the neck. 

9. Never results from this cause unless 
it has first given rise to some men- 
strual or uterine disorder upon which 
the aphonia is secondary. 

10. Is almost invariably preceded or at- 
tended by symptoms of spinal irrita- 
tation, more especially by tenderness 
upon pressure on some of the cervical 
and dorsal vertebras. 

11. When chronic, it invariably depends 
upon some uterine or cerebro-spinal 
lesion. 



You should be careful not to confound the hysterical aphonia 
with the apoplectic. The apoplectic habit, as well as the more 

decided symptoms of cerebral congestion in a 
tic D aphoni S l s from apoplec " given case, would remove all sources of fallacy 

in the diagnosis of these two affections. In the 
hysterical aphonia, in .addition to the general uproar of the func- 
tions, the result of over excitement, there is an evident lryperses- 
thesia of the brain and spinal cord. In the apoplectic condition 
the loss of voice is a tolerably certain and characteristic symptom 
of congestion of the medulla oblongata. The respiratory ganglia are 
almost certain to suffer from this engorgement, and the organs to 
which the pneumo-gastric nerves are distributed, first the larynx, 
and afterward the heart and lungs, are necessarily implicated in the 



292 LECTURES, CLINICAL AND DIDACTIC, 

resulting disorder, the cause is centric, and the consequences are 
apt to be disastrous. The hysterical aphonia is always more 
alarming than serious. 

The gastric affections that partake of an hysterical character are 

almost invariably consequent upon uterine luxations or ulceration, 

dysmenorrhoea, leucorrhcea, pregnancy, lacta- 

Gastro-hysterical disorders. . .,.*.. rrM -, 

tion, or spinal irritation. ine dyspeptic symp- 
toms are of reflex origin, and differ essentially from those which 
are present in the more ordinary forms of sub-acute gastritis, gas- 
trodynia, gastralgia, etc. In most cases of obstinate digestive 
derangement occurring in women during their menstrual life you 
will observe more or less of the hysterical complication. There 
is the increased suffering at the month, the fickle character of the 
pains, the capricious appetite, the exaggerated complaint of suf- 
fering, and the alternation of the uterine or spinal with the gas- 
trointestinal symptoms. I will speak of this subject more partic- 
ularly at another time. 

Hysteria is frequently confounded with insanity. But the aber- 
ration of the mental faculties in the former affection is almost 
invariably related to disorders of menstruation, 
wtnsanit ° f hysteria to pregnancy, or to post-partum contingencies. 
Moreover, as in puerperal mania, it is usually 
self -limited, and if not mal-treated, is neither severe in degree nor 
of long duration. In insanity there is evidence of real cerebro- 
mental disease. The reproductive function is not necessarily im- 
plicated, either as cause or effect. The delirium is more lasting. 
In hysteria the mind is fickle and capricious, the emotions run 
riot, and, as Sydenham long ago observed, the patient " observes 
no mean in anything, and is constant only to inconstancy." 

In insanity there is a manifestation of a strong mental bias. 
There is usually much depression of spirits, which is the result of 
a fixed delusion, of which it is impossible to dispossess the mind 
of the patient. In hysteria a little tact will enable you to recog- 
nize a species of cunning shrewdness that is well calculated to 
deceive. In insanity there is an honest and grave -sincerity and 
earnestness that will withstand any amount of analytical cross- 
questioning. A woman with the hysterical form of insanity 
almost invariably dislikes those whom she has hitherto loved the 
best, and towards whom she sustains the most endearing relation. 



ON THE DISEASES OF WOMEN. 293 

She may exhibit a decided aversion to her husband, and would 
perhaps even destroy her children. Removal from home, more 
especially if she is not permitted to see her family very frequently, 
will do much toward effecting a cure of her strange and tempo- 
rary hallucination. In case of uncomplicated insanity the victim 
is as prone to suspect and to conceive a dislike for one member of 
the household as for another. 

Hysteria is a paroxysmal disorder, with a great variety of nerv- 
ous and visceral complications, none of which are, strictly speak- 
ing, pathognomonic. Insanity is not regularly paroxysmal, 
although it may be marked by recurring fits of greater or less 
duration and severity. If we except paralysis, organic nervous 
complications are usually lacking in insanity. Both are hereditary 
disorders, but the predisposition to hysteria is more marked, more 
easily aroused, and more easily acted upon by exciting causes than 
in the case of insanity. In exceptional cases they may co-exist. 



294 LECTURES, CLERICAL AND DIDACTIC, 



LECTURE XVIIL 

hysteria — (continued). 

Gentlemen : 

The hysterical delirium is in many respects peculiar. It is -liable 

to occur in typhoid, typhus, the eruptive and puerperal fevers, and 

also in certain menstrual and hepatic disorders. 

Hysterical delirium. . 

In a case either 01 typhoid or typhus lever, 
occurring in a young or middle-aged woman, if the delirium per- 
sists after the more acute symptoms have subsided, and especially 
if there is no particular evidence of cerebral lesion ; if the parox- 
ysms thereof return at irregular intervals, and result from trivial 
causes, which in one who was seriously ill would have little effect ; 
if the mind is more than usually fitful and capricious, or if it be 
inclined to dwell upon a single train of ideas, which have grown 
out of the most ridiculous fancies ; if these vagaries are outre and 
otherwise inexplicable ; you will be led to suspect the Irysterical 
complication. And your suspicion would be confirmed by any 
evidence of malingering on the part of the patient. 

She will not look one directly in the face. Her eye is averted, 
cast down and expressionless, like that of a young man with sper- 
matorrhoea which has been brought on by self- 

The patient's manner. • i i i t • i i 

abuse. Or it has a roguish look, and twinkles 
with evident satisfaction at the alarm and discomfiture of the 
bystanders, upon whose sympathies she may have been playing as 
upon a harp. During the fit, in assumed fear of dysphagia, or 
from a settled determination that nothing shall pass her lips, she 
ma} r peremptorily refuse to swallow either food or medicine. 

She is sensitive, impressible, tearful. Her perceptive faculties 
are intensified. She sees and hears every motion that is made in 
the house. Nothing escapes her. For her to remain passive is an 
impossibility. She is under the dominion of an evil genius, which 
destroys her own peace and that of all concerned. 



ON THE DISEASES OF WOMEN. 295 

This form of delirium is likely to be caused or aggravated by 

the taking of drugs to blunt the sensibilities and to compel the 

patient to rest and sleep. Any of the narcotics 

Aggravated by drugs. . ,• t i •> 

may m exceptional cases produce an opposite 
effect from that which was intended. Under these circumstances 
they increase the perturbation and unhinge the nervous sympa- 
thies more and more. Even when the patient is easily narcotized, 
it is doubtless true that the habit of taking such remedies as the 
bromide of potassium or the hydrate of chloral, in increasing 
quantities, may finally work serious mischief. 

During the convalescence of fevers, the hysterical delirium may 
be suddenly developed in consequence of an incidental derange- 
ment of the menstrual process. The same is 

Incident to fevers. . 

true oi a tardy resumption of the ovarian and 
uterine functions after delivery or prolonged lactation. Until the 
organic processes have resumed their natural order, and the period- 
ical discharge appears, there is danger, especially after acute 
disease, of the mental functions becoming temporarily impaired. 

The hysterical delirium is often present in child-bed fever^ how- 
ever mild its type. In this case it arises from reflex causes, and 

we very naturally refer the symptoms to some 

In child-bed fever. J . J . , . t t . 

remote lesion of the soft parts withm the pelvis. 
This delirium varies in its intensity with the quantity and quality 
of the lochia and of the lacteal secretion, being less marked and 
persistent if these post-partum products are freely and uninter- 
ruptedly poured out. It also varies with the gravity of the uter- 
ine lesion. Even in the most aggravated cases of delirium and 
puerperal mania, it is quite absurd to speak of a metastasis of 
uterine phlebitis, or of utero-peritoneal inflammation to the brain. 
In rare cases the hysterical delirium is complicated with a form 
of hypochondriasis that results from some chronic hepatic disor- 
der. If uterine lesions are conjoined with an 
hy^oc y hond C r iasis licated wkh °^ or g an ^ c disease of the liver, and the patient 
has delirium, that delirium is necessarily of 
serious import. Hepatic abscess may co-exist with uterine dis- 
placement, ulceration, or enlargement, and a form of delirium 
exist which is both hysterical and hypochondriacal. In such a 
case the danger is increased by the resorption into the blood of at 
least one of the post-organic elements of the bile, viz. : the eho- 
lesterine. 



296 LECTURES, CLINICAL AND DIDACTIC, 

It is less difficult to separate listeria from hypochondriasis than 

from the more decided forms of insanity. In hysteria the mental 

derangement is not always, or indeed usually, 

Diagnosis of hysteria from f a desponding or gloomy kind. The attack 

hypochondriasis. - 1 - ~ o J 

comes on suddenly and without warning ; is 
explosive in its nature. The classes of persons predisposed to the 
two diseases are of very different habits of thought and tempera- 
ment. Those most liable to hysteria are the fitful and the frivo- 
lous, such as have not taken especial pains in the culture of the 
reflective faculties. Hysteria is limited almost exclusively to 
women. A majority of cases of hypochondriasis occur in men. 
Aristotle observed that "melancholy men are the men of the 
greatest genius." Hysteria affects the perceptive, hypochondriasis 
the reflective faculties of the mind. In the former it is intact and 
the perceptions are morbidly acute. In the latter the gloomy 
forebodings, the delusional insanity, impair all the mental pro- 
cesses ; the perceptions are misinterpreted, and the judgment is 
perverted. When hysterical females become hypochondriacal, 
their thoughts almost always take a religious turn, and the delu- 
sion develops into a mild form of theomania. 

I was recently consulted in a case of this kind by my friend and 
former pupil, Dr. C. N. Dorion, of this city, from whom I have 
the following details concerning his patient : 

Mrs. M , 25 years of age, was married two years ago, but 

has no children. Her complexion is sallow, 
the menses are regular, but, for the last four or 
five months, rather scanty. The appetite is variable, the bowels 
are somewhat constipated. She suffers no pain excepting an 
occasional attack of headache which is not very severe. Her con- 
stitution appears to be good. Her face wears a melancholy 
expression. Her father is subject to fits of hypochondriasis, and 
one of her sisters has been insane for several months. 

Last summer she made a visit to that sister, and spent some 
days with her in the insane asylum. Since that visit she has been 
very much afraid of becoming insane herself, and has a mortal 
dread of dying in a mad-house. She is in terror of being left 
alone. When her husband leaves home in the morning, she feels 
sure that she will never see him again. Her mind runs constantly 
upon religious topics, and she will sit and sing hymns for hours 
together. She has lost all interest in domestic affairs, and the 
outside world is a complete blank to her. 



ON THE DISEASES OF WOMEN. 297 

When lying down she fancies that it will be quite impossible 
for her ever to rise again, or to walk if she were upon her feet. 
She thinks and says that she is too weak to do anything. Occa- 
sionally there are nervous shiverings, globus hystericus, cold 
extremities, and, at rare intervals, an intermittent pulse. The 
tongue is coated white, but there is no febrile action. She broods 
over her certain death, her possible insanity, her sins always. 
When one succeeds in diverting her attention temporarily, she is 
apparently quite well and says that she is no longer sick. But in 
a short time she lapses again into the same pitiable state of mind 
as before. She insists that for weeks past she has not been able 
to sleep, even for a single hour. 

Among the hysterical contingencies and sequelae of labor none 
are more embarrassing than those which simulate puerperal peri- 
tonitis. Post-partum hysteria is sometimes 
P eritonmi terical form ° f vei T difficult of recognition. We most natur- 
ally look for it in those who in the unimpreg- 
nated state have been subject to mental unsteadiness, and who 
through original or acquired predisposition are considered to be 
"nervous." The changes incident to gestation frequently have 
the effect to fortify against an hysterical outbreak until " term " 
has arrived. But either during or subsequent to delivery the old 
habit is revived, and symptoms of hysteria may crop out again. 

In this spurious form of peritonitis the attack comes on ab- 
ruptly and without any obvious cause. It may even be entirely 
emotional in its origin. Everything may be 

Differential diagnosis of. . ° J t> J 

natural with the lying-in woman when a slight 
mental shock has the effect to make her •alarmingly ill. There is 
local pain and tenderness over the abdomen. She can not bear 
slight pressure, the weight of the bed clothing is unsupportable, 
the lower extremities are sometimes but not always flexed, the 
abdomen is tympanitic, the urine is either scanty or suppressed. 
The skin is neither unnaturally hot nor cool. She has no decided 
chill, but may ha^e rigors. The pulse is nearly or quite natural. 
If at all changed it will usually be found slower than at your last 
visit. The delirium is hysterical. If, for example, you attempt 
to administer a remedy in the form of a little powder, she will 
seize it and tear the paper to pieces in a twinkling. And this 
most deliberately and defiantly, perhaps. She clenches her teeth, 
closes her lips, thrusts her face into the pillow, tosses about from 



298 LECTURES, CLINICAL AND DIDACTIC, 

side to side, or persists in sitting up, even although she may be so 
sleep} 7- as scarcely to be able to keep her eyes open. 

Now, in genuine child-bed fever, although there is no pathog- 
nomonic lesion, any more than in surgical fever, to which it is 
closely allied, the symptoms differ essentially from those which I 
have just enumerated. If there is perimetritis, endometritis, peri- 
tonitis (ovarian or abdominal), or metro-phlebitis, the usual con- 
stitutional signs of local inflammation will be present. 

Thus, in true puerperal peritonitis, we shall have a characteris- 
tic frequenc}^ of the pulse, which continues despite a copious 
diuresis or diaphoresis ; a decided chill at the onset of the attack, 
as in inflammation of serous membranes elsewhere ; severe frontal 
headache ; a suppression of the milk and of the lochia ; excessive 
abdominal distension and tenderness, which latter is greatly in- 
creased by extending the limbs or allowing the clothing to fall 
upon the tumor ,- and a hippocratic expression of the countenance. 
In the worst cases the period of collapse sets in early, and the 
patient may die in a very few days, or she may linger for a week 
or more. 

In private practice puerperal peritonitis is a rare affection. 

Probably not one-half the cases of this disease that are reported 

in our medical societies and journals deserve to 

A suggestive item. 

be classed as such. The clinical history of such 
cases proves many of them to have been spurious, self-limited, 
incidental, hysterical. Any remedy capable of controlling the 
nervous symptoms, which are contingent upon labor, is very 
likely to get the credit of aborting a genuine attack of peritonitis. 
The same is true of the hysterical side-ache which resembles 
pleurisy and is so often mistaken for it ; and also of the hysteri- 
cal pains which sometimes counterfeit rheumatism so closely. 
When you hear a physician say that he has often succeeded in 
curing anyone of these diseases — peritonitis, pleurisy or rheu- 
matism," in a few hours with this or that remedy, you may safely 
conclude that his clinical observations have not been very accu- 
rate, and that he is claiming too much for his skill. 

There is a singular and significant relation between abdominal 
tympanites and the mental derangements, more particularly the 
forms of delirium, to which hysterical women are liable. It 
frequently happens that the degree of abdominal distension is 



ON THE DISEASES OF WOMEN. 299 

a measure of the temporary disorder of the brain. Whether this 

tumefaction of the abdomen, and sometimes of 

Abdominal tympanites ^he hypoffastrium also, is to be regarded, in the 

and delirium. J \r O o 

light of cause or effect, authorities are not agreed. 
It is incident to difficult and delayed menstruation, to the puer- 
peral state, to abortion, to uterine displacements, and to the vari- 
ous forms of sexual irritation from whatever cause. It is some- 
times brought on by mental shock or emotional influences of 
different kinds, as fear, anger, grief or disappointment. You will 
find in these cases that the abdomen is excessively tender to a 
slight touch, but not to steady and continued pressure. This dis- 
tension may come on very quickly and disappear as suddenly, 
without being accompanied or followed by any local inflamma- 
tion. I have known it to be caused by drinking a glass of ice- 
water, or eating a dish of ice-cream, during menstruation. In a 
few minutes after taking the latter the abdomen was found to be 
enormously swollen and the patient delirious. Similar states of 
the mind are incident to the tympanites intestinalis of puerperal 
and typhoid fevers. But, in many cases of hysterical tympanites, 
which are really due to derangement of function in the solar 
plexus and semilunar ganglion chiefly, you will observe that con-, 
tinued pressure upon the stomach and abdomen, when the pa- 
tient's attention is diverted, will not only arrest the unnatural 
secretion of gas, but will cause both the swelling and the delirium 
to subside. This is sometimes quite diagnostic. 

Hysteria may counter- Hysteria -may simulate natural labor. A marked 
feitlabor - case of this kind is reported by Dr. Hodges.* 

"T was engaged to attend a married woman in her confinement 
for the first time, then believed by herself and friends to be about 
five months advanced in pregnancy. Time went 
on — the usual preparations were made — the 
nurse secured, the patient happy in the thought of becoming a 
mother, and pleased with the sympathy elicited from the neigh- 
bors in relation to the approaching event. In four months after 
the first intimation I received, I was requested, at about ten o'clock 
at night, to visit her, and to do so with as little delay as possible, 
for she had been ill all day, and was reported to be getting rap- 
idly worse. On arriving, the pains were very severe, and of the 
kind attending the last stage of labor. I was pleased to hear 
from the nurse that the pains had been very regular all the day, 

* Trans, of the Obstetrical Society of London, Vol. I,fp. 339. 



300 LECTURES, CLINICAL AND DIDACTIC, 

gradually increasing in frequency and intensity, for the hope of a 
night's rest was before me. They certainly were most severe and 
forcing, and succeeded each other so rapidly as to give the impres- 
sion that the process would soon be completed, and the first casual 
vaginal examination conveyed to my mind the same idea, for I 
detected a soft, fluctuating tumor, filling the vagina, and which, 
during pain, distended and protruded it through the os externum, 
precisely as in natural labor when the membranes protrude. I 
made no observation to those around me, for the pains were so 
urgent and forcing that I believed the labor would be over in a 
minute or two ; but their continued severity brought no advance- 
ment — no alteration. I then examined carefully into the cause 
of this apparent delay, and found that the tumor was a vaginal 
cystocele, or prolapse of the anterior parietes of the vagina, 
caused by an enormously distended bladder. The finger was 
with difficulty passed up behind this swelling, where the uterus 
was discovered with its mouth closed and of the unimpregnated 
size. The patient and attendants were then informed that, not 
only were these pains spurious, or false, or hysterical, * * * 
but that the patient herself was not even pregnant, which fact 
astonished them still more, and amused them for many a day. 
* * * The patient before marriage was subject to frequent 
attacks of hysteria, and about one year previous to this event was 
present at a relative's accouchement, where the pains were severe 
and the labor protracted." 

Hysteria and epilepsy are frequently confounded by those who 
pay too little attention to diagnosis. The points of difference 

between them concern the coming on of the 
fro^i ia fpi°epsy° f hysteria paroxysm, the symptoms during the fit, and 

those which immediately follow it. In epilepsy 
there is usually some premonition of the spasm ; the patient may 
fall to the floor, or the fit may come on immediately upon awaking 
out of sleep ; the aura epileptiea is more or less pronounced ; the 
attack is not strictly referable to an emotional cause, but is apt 
to be periodical, occurring once in so many hours or days ; it has 
no necessary relation to menstrual disorders, to the return of the 
month, or to enfeebled conditions of system consequent upon ges- 
tation or lactation. The hysterical fit follows some mental shock 
or strain ; comes on gradually, usually with more or less of gastric 
disturbance and distress, choking, suffocation, globus hystericus, 
twitching and convulsive movements of the eyeballs and the eye- 
lids ; is very apt to folloAv in consequence of loss of sleep ; and if 



ON THE DISEASES OF WOMEN. 301 

at all periodical, it is more likely to recur at the month as a con- 
tingent of menstruation. In certain cases pregnancy and lacta- 
tion may predispose to it most decidedly. 

In the epileptic fit there is a sudden and total loss of conscious- 
ness. The face becomes livid and distorted ; a frothy saliva flows 
from the mouth, and there is grinding of the teeth and biting of 
the tongue. The patient is entirely oblivious to all that is pass- 
ing. The convulsive movements affect the muscles of the face, 
neck, throat, chest and extremities. The larynx is spasmodically 
closed, and hence the discoloration of the skin, and the temporary 
arrest of breathing. When the spasms reach the muscles of the 
extremities, those on one side of the body are apt to be more 
decidedly affected than those on the other. These spasms are 
more tonic than clonic. The movements of the patient are 
entirely involuntary. 

In the hysterical paroxysm, if the patient becomes comatose 
(which is exceptional), this condition comes on very gradually 
and may not be complete until at the close of the fit. The face 
may be flushed, but it is not dusky or livid in hue ; she does not 
foam at the mouth ; as there are no convulsive movements of the 
lower jaw, the tongue is not apt to be bitten ; and, what is quite 
distinctive, she displays something of volition in all her move- 
ments, and evidently "keeps the run" of what is going on around 
her. She sighs, or laughs, or sobs, or perhaps talks as if dream- 
ing. The muscles of the face are seldom convulsed ; the face 
itself is not disfigured ; the larynx, which is the gateway of the 
respiratory system, remains open ; and the movements of the 
extremities are always partly under control of the will. 

The epileptic paroxysm is generally of short duration and 
passes off with profound sleep, from which the patient awakens 
without the remotest idea of what has passed since the onset of 
the attack. Whether sleep follows the fit or not, there is con- 
siderable dullness and hebetude of mind which may continue for 
hours or days, and which finally, if the fits recur very often, 
impair the intellect and render the patient a complete wreck. 

The hysterical coma may become more profound and the patient 
may sleep toward the close of the paroxysm, but the rule is that 
the fit passes off with an ebullition of emotional feeling. She 
may either weep or laugh immoderately. Or she may sigh and 



302 LECTURES, CLINICAL AND DIDACTIC, 

groan and sob, and all this without any real mental anguish to 
correspond with these demonstrations. Her emotions run riot, 
and are sometimes most grotesquely jumbled together. She may 
know more of what has passed since the commencement of the 
attack than the bystanders themselves, and the only perceptible 
effect of a repetition of these paroxysms seems to be so to shatter 
her nervous system as to make her more and more susceptible to 
them. In many cases the fit terminates with a copious flow of 
pale, limpid urine. 

You will hardly fail to be consulted for the relief of certain 
hysterico-neuralgic affections of the spine. These affections are 
very distressing because of their chronic na- 
irrkSbn^' ° r " spInal tuEe., their proneness to seize upon some of the 
most intelligent, gifted and amiable women in 
society, and because it almost always happens that before you are 
applied to, they will have done the very thing, and resorted to 
the very means best fitted to fasten the disease upon them. In 
these patients some portion of the spine — it may be a spot over 
the spinous process of a single vertebra, or perhaps the whole 
length of the column — becomes exquisitely sensitive to the touch. 
The pain may be sharp or dull, radiating, shooting, shifting, tran- 
sient or permanent, and is very apt to be increased b}^ over-fatigue 
of body or mind, vicissitudes of weather, as of cold and damp, 
strong mental emotions, sleeplessness, obstinate constipation, and 
the return of the menstrual crisis. It renders walking impossible 
in many cases, and may even interfere with riding also. The inci- 
dental symptoms vary with the seat of the local pain, but are not 
as serious as you would be led to infer. Indeed, the exaggerated 
character of the complaints that are made will prevent your con- 
founding this with caries of the vertebrae, or with myelitis or spinal 
meningitis. The predisposition to this disease is the hysterical dia- 
thesis ; the exciting cause may generally be found in some derange- 
ment of the menstrual function upon which the " spinal irritation " 
is secondary. Such patients sometimes suffer extremely from neu- 
ralgia in various parts of the body. Exercise gives them so much 
pain and unrest that they soon desist from taking it, and finally 
become bed-ridden and wretched. 

Sometimes this peculiar disease locates itself in one of the larger 
joints, particularly in the hip or the knee. Dr. Simpson reports a 



ON THE DISEASES OF WOMEN. 303 

case in which the pain was seated in the head of the right radius. 
The knee-joint is most frequently affected. 
th? y oint r s Cal affectIons of There is the greatest dread of motion of the 
affected part, and the pain is said to be excru- 
ciating in degree, much more, indeed, than in case of real ulcera- 
tion of the cartilages. This affection, which is comparatively- 
frequent, was first described by Sir Benjamin 

Diagnosis of. .. . . j . 

Brodie, who says, concerning its diagnosis, that 
" There is always exceeding tenderness, connected with which, 
however, we may observe the remarkable circumstance, that 
gently touching or pinching the integuments in such a way as 
that the pressure can not affect the deep-seated parts, will often 
be productive of much more pain than the handling of the limb in 
a rude and careless way." A good plan is to divert the patient's 
attention from herself while you are manipulating the affected 
part, by which means you will find it possible to move the joint 
with little comparative complaint from her. If she insists that 
the limb can not be moved or straightened voluntarily, you may 
resort to anaesthesia by ether or chloroform as a means of making 
a more careful diagnosis ; for it is really very important to decide 
in these cases whether the disease is or is not hysterical. It has 
frequently happened that women have been kept in bed, in the 
horizontal posture, for weeks and months, and even for years, 
when there was no actual disease of the joint itself. Indeed they 
have often gone through the martyrdom of blistering, cupping, 
leeching, salivation, and finally of amputation, for the cure of this 
reflex disorder. 

If you remember the distinctive characteristics of hysteria that 
have already been enumerated, you will be spared the commis- 
sion of such blunders, and your patients saved from the prolonged 
suffering which, as a rule, may be easily remedied. 

In the unmarried, and sometimes in women who are married but 

who have not borne children, vaginismus is an attendant upon 

hysteria. In exceptional cases the hvsterical 

Other incidental diseases. tip p"t 

disorder appears under the iorm ol nymphoma- 
nia. Numerous instances are recorded in which ovariotomy has 
been attempted, when on opening the cavity of the abdomen the 
tumor has proved to be an hysterical phantom. 

Nature. — But it must suffice to say that hysteria is rather a 



304 LECTURES, CLINICAL AND DIDACTIC, 

condition than a disease per se. This condition appears to consist 

in a peculiar irritability and impressibility of the 

Hysteria not a bona fide nervous system, which is so modified by disor- 

disease. d ' J 

ders of the sexual apparatus as to cause it to 
differ from every other kind of nervous derangement. This mor- 
bid irritability should be regarded in the light of a peculiar dia- 
thesis, upon which, as we have seen, almost any disease may be 
engrafted. Roberton says very explicitly : * " We have reason to 
believe that there is as absolutely an hysteric constitution, or con- 
genital predisposition to Irysteria, as that there is a scrofulous con- 
stitution, or congenital predisposition to scrofula ; and conse- 
quently that none are liable to hysteria but only such as possess 
this constitution. 

" The hysteric condition is characterized by irritability, sui gen- 
eris, of the nervous system as a whole, or sometimes more partic- 
ularly as connected with certain organs ; and although this condi- 
tion can not propably be originated in the individual by modes of 
living, and other external circumstances, it may be aggravated by 
them." 

In what this hysterical predisposition really consists we do not 
know. How it is that it reverses the finer traits and characteristics 

of womanhood, whether temporarily or perma- 

Its real nature is unknown. 

nently, it is impossible to comprehend, I hat 
such are among its effects is a thing of e very-day observation. It 
is at the bottom of half the disease and the unhappiness of the 
sex. It may turn the wife against her husband, the sister against 
her brother, the daughter against her father, the mother against 
her child, and friend against friend the world over. Its strange 
characters may be traced upon every page of human history. In 
the affairs of church and of state, in medicine and morals, in soci- 
ety at large and in the sick-chamber, its influence is certain to be 
felt. It does not destro}^ life directly, but indirectly it has slain its 
thousands. In brief, it is the most mischievous and the most 
enigmatical and elusive of all those elements which enter into the 
formation of " poor, weak, human nature." 

Prognosis. — Uncomplicated hysteria is not a fatal disorder. It 
ma3% however, serve to conceal the graver symptoms of disease 

* Essays and Notes on the Physiology and Diseases of Women. London, 1851. 
P- 237. 



ON THE DISEASES OF WOMEN. 305 

under cover of such as are not serious, and in this manner tends 

to destroy life by causing the real lesion to be overlooked. Let 

me illustrate : A delicate, nervous woman is 

Illustration. . 

seized with a sharp attack 01 pleuro-pneumoma. 
In the emergency of her sudden illness an officious neighbor is 
called in. This impromptu nurse has a voice and manner that 
serve only to excite the patient more and more, and, despite her 
bundle of expedients, some of which, if properly applied, might 
have been efficacious, the symptoms are aggravated. The reflex 
effect of that woman's presence and performances upon the sen- 
sibilities of such a subject is so to shock and derange them, that 
it may be quite impossible for the doctor when he arrives, to discrim- 
inate properly between the symptoms that are presented. He 
can not tell which of them are genuine and which are spurious, 
for the former are masked, while the latter are lashed into undue 
prominence. All the symptoms that are chargeable to the nurse's 
lack of tact, to her incompatibility and to surrounding circum- 
stances generally, rather than to internal conditions of the patient's 
organism, will be likely to deceive and mislead the physician. 
Vesical or rectal tenesmus, globus or clavus hystericus, fugitive 
and excruciating local pains and spasms, a temporary diabetes in- 
sipidus, aphonia, hysterical vomiting, amenorrhcea, or a host of 
other irrelevant symptoms, not one of which has any characteristic 
relation to the original disease, are so magnified, and stand out so 
clearly and prominently, as to divert his mind into the wrong 
channel. 

Under these circumstances, and especially if he is inexperienced, 
the physician may feel himself called to prognosticate a fatal issue. 
Taking the wrong cue, adding to the alarm instead of arresting 
it, and causing matters to become worse in compound ratio — for 
doctors are either helpful or harmful — the patient may finally die, 
not indeed of hysteria, but of the pneumonia which has been per- 
mitted to run its course without interruption, because it has been 
overlooked. 

Or, if the physician in charge has had sufficient experience, and 
has tact enough to enable him to recognize the hysterical out- 
growth in such a case, but is withal very much occupied, and 
weary with this class of patients especially, he may hastily con- 
clude that she has a fit of hysteria and prescribe accordingly. 



306 LECTURES, CLERICAL AND DIDACTIC, 

Meanwhile the real disease is making rapid progress, and before 
his next visit it may have become incurable. 

Now it is this deceptive exaggeration that is likely to mislead, 
and to cause us to misjudge, to overrate, or to underrate the dan- 
ger in cases of hysteria complicated with other forms of disease. 
Some of the verbal and objective signs are untruthful. They in- 
troduce the lying element into the record, and hence the difficulty 
in detecting them and in assigning their proper diagnostic and 
prognostic value. 

Treatment. — Before we proceed to the special therapeutics of 
this affection, there are some considerations 

General remarks. . .. . 1 . 

which demand our notice, and which are essen- 
tial to its proper and successful treatment. 

This disorder being chiefly emotional in its origin, and indeed 
in its very nature, it is vitally important to obtain such an in- 
fluence over the mind of the patient as will 

Cental remedies. 

serve m a measure to control the symptoms, or 
at least to place her in a state in which our remedies will act 
more promptly and efficiently. There can be no doubt that very 
many cases of hysteria, in some of its protean forms, have been 
unwittingly cured by means that were suited to occupy, divert, 
overwhelm, or control the emotional faculties. Such expedients 
are to be regarded only as auxiliaries to proper treatment, but as 
such they are so useful, and sometimes so necessary, that they 
should not be overlooked. For it has often happened that the 
manner and bearing of the nurse, or of some kind-hearted neigh- 
bor who has been called in, has done a thousand times more to 
cure these patients than the physician's prescription. The intan- 
gible, but no less potent influences of fear, faith, hope, confidence, 
will, reason, diversion, management, occupation of the mind, ar- 
gument, concession, opposition, sympathy, indulgence of caprice, 
helping her to bear her burdens — whether real or imaginary — 
change of diet, air and scenery, are sometimes indispensable. And 
unless we can use them appropriately, or the patient shall happen 
to be accidentally brought under their influence, the best chosen 
remedies will utterly fail of effect. 

Herein lies the difficulty in controlling and curing the various 
forms of hysteria. The most inexperienced among you might 
match a great many of the symptoms mechanically, and prescribe 



ON THE DISEASES OF WOMEN. 307 

for them secundum artem. But, unless you are able to recognize 
which of them are genuine and which are 

The real problem. . 

not ; unless you can separate the real irom the 
spurious ; unless you can refer those which are hysterical to their 
proper source, and succeed in reducing the emotional disturbance 
of the patient to order, you will fail to cure this disease. 

Now, there are many ways of accomplishing this object. You 
know that hysterical patients are eccentric. For this reason it 
requires a large measure of tact (which can only be acquired 
through observation and experience) to manage them properly, 
and to cure them most certainly and promptly. I can no more 
tell you what to do in each particular case of hysteria than I 
could define the odor of small-pox or of measles. But it is pos- 
sible to give you some general directions that shall be useful. 

In the first place, if you desire to be most successful in treating 
this class of diseases, you should maintain your distinctive char- 
acter as physicians. For there is a species of 
the docto7' n s g hibu e s nds upon mutual reserve and respect which should sepa- 
rate the physician from his patients, and which 
invest him with a peculiar influence over them. If this is prop- 
erly maintained, it need not subtract from the social character 
and position upon which so much of his general reputation de- 
pends. But it will give him an immense advantage in the man- 
agement of every kind of hysterical disorder, to which so many 
of his lady patients are subject. 

Nor is a highly- wrought, delicate, impressible, nervous woman 
likely to be benefited by the advice of a physician whose personal 
habits and manners are repulsive to her, and 
dreV s s ,°etc! s personal ad ~ whom she is compelled to tolerate rather than 
esteem. In this, as in other matters, trifles 
have great weight. I have known a brother practitioner, who 
was skillful and competent, to be discharged by such a patient 
for the reason that " he never wore a decent cravat." His slovenly 
habit more than counterbalanced the effect of his remedies, and, 
while he continued to visit her, his patient grew worse instead of 
better. The good influence of one physician may be crippled by 
his loquacity, another is too taciturn ; a third asks too many, and 
a fourth too few questions of the patient ; one brings too full a 
budget of news from a neighbor ; another is eternally canvassing 



308 LECTURES, CLINICAL AND DIDACTIC, 

for his school of medical practice, his church, his club, or his 
political party ; one is too cross, while it is alleged that another is 
" altogether too kind.'' 

This is but a scanty list of personalities, any one of which may 
serve, in this class of diseases especially, to neutralize the curative 

effect of his remedies. You are not to suppose 
always t^vliT ltems not that they are insignificant merely because they 

are not alluded to in your text-books. What- 
ever can by any possibility constitute an obstacle to recovery is 
important and worthy of your attention. Fortunately most of 
these vexations are avoidable. You will not all excel in obtain- 
ing the confidence of your patients, and in bringing them into 
that passive state in which they can be most readily cured. But 
each of }~ou can by education acquire such a measure of tact and 
of adaptation to caprice and circumstance as will multiply your 
resources and render you many times more useful to them. 

I am so confident that a lack of sympathy, a dearth of feeling, 
a real incompatibility of temper and taste between the physician 

and his hysterical patient may cause his treat- 

Incompatibility between n , ■ p i ,1 n n 

physician and patient. ment to result m more oi harm than ol good, 
that, in case this obstacle can not be otherwise 
removed, I think it better to withdraw and to let another phy- 
sician be called. Indeed, I have sometimes voluntarily discharged 
myself, after having frankly told the patient and her family that, 
for some unknown reason, my remedies had 

How to remedy it. . . 

failed to cure her ; and that, m my judgment, 
such a change was what she most needed. Under similar circum- 
stances we would not hesitate to discharge the nurse whose every 
movement was annoying to the patient and antagonistic to her 
comfort and welfare. And I do not know why the same rule 
should not also apply to the doctor. If a new face and a new 
method of prescription will work the desired change in her feel- 
ings and her symptoms, by all means let them be tried. For these 
things can operate through the emotions, and may entirely super- 
sede the necessity for remedies of whatever kind. And by fol- 
lowing this rule, although you lose the credit of curing one such 
patient, you will gain the reputation of saving another ; for, when 
the wheel turns around, your face and your manner may be the 



ON THE DISEASES OF WOMEN. 3Q9 

one thing needful in a similar case which your professional neigh- 
bor has failed to relieve. 

In lieu of controlling the emotional outbreaks and suffering in 

hysteria, by the personal tact, charapter and magnetism of which 

I have spoken, these subjects are often brought 

Narcotics and Anti-spas- unc [ er the quieting influence of narcotics and 

modics. J- o 

anti-spasmodic s of various kinds. But such 
medicines are mischievous, and should be given under protest and 
exceptionally, or rather not at all. One reason why there are so 
many nervous women in our day is, that the habit of taking such 
drugs is almost universal. And every few months a new one is 
added to the list. Thousands of women, who should be well and 
healthy, are just now under the slavish domin- 
ion of the hydrate of chloral and the bromide 
of potassium. The taking of these substances habitually begets 
a predisposition to nervous disorders which grows apace. So that 
if there were no other reason for withholding them from our 
prescriptions, we should not give them freely and indiscriminately, 
lest the habit be formed in consequence. 

There are, however, exceptional cases in which this means of 

temporary relief can not be rationally excluded. When from 

excess of pain, fatigue, or excitement, it is ab- 

Sometimes permissible. 

solutely impossible otherwise to procure the 
needful rest, they are perhaps permissible. But these are excep- 
tional cases in which we must choose between two evils. It may 
be better to compel sleep, to overwhelm the nervous centers, and 
to run the risk of the secondary consequences of such an expedi- 
ent, rather than let the patient wear herself out with unrest, 
extreme pain, or protracted insomnia. 

Concerning the propriety and advisability of alcoholic stimula- 
tion in the weakened conditions of the nervous system, which 
predispose to, and attend upon hysterical dis- 

Alcoholic stimulation. . . 

orders, physicians are not agreed. One class, 
of which Dr. Skey is the modern representative,* considers them 
indispensable, and insists that they should be given freely and 
promiscuously. On the contrary, what might be called the de- 
nunciatory school is equally positive that in all forms alcohol is 
always injurious. 

* Skey on Hysteria. A. Simpson & Co., N. Y., 1S67. 



310 LECTURES, CLINICAL AND DIDACTIC, 

This involves a question which can not be settled for you in 
the lecture-room. If you are satisfied that these agents can be 
utilized in correcting the mal-nutrition and depraved vitality 
from which this class of patients often suffers preeminently, it 
will be your duty to prescribe their sparing and transient use. If 
you need to husband the vital resources of one who is exceedingly 
weak, and almost bankrupt in strength, and are satisfied that 
alcohol, or tea, or coffee will diminish disassimilation, and prove 
a veritable " savings bank to the tissues,"' as Moleschott so 
quaintly terms it, you should not withhold them. 

Under certain circumstances it may be quite as necessary to 

furnish a rapidly oxydizable material to the organism, as in other 

conditions it is to supplv oxvgen itself. I might 

Folly of dogmatizing. .. . " -i • i 

insist that wine, brandy or whiskey have never 
been of the least service in any case of hysteria. But that would 
not alter the facts. Individual observation is too limited to justify 
such assertions. Indeed, these arbitrary rules have very little to 
recommend them. I have known weak, nervous, delicate women 
to be disabled and bed-ridden for months and years because their 
physician obstinately denied them the little stimulus which they 
craved, and the temporary use of which would have set them 
upon their feet again, without doing any possible harm. 

So far as my own experience extends, I have found it best to 
discriminate carefully, and to prescribe one or another of the dif- 
ferent preparations of alcohol only when I could 

Qualified use of stimulants. . .. 

not do better, and when there was no especial 
danger of reviving an old habit, or of forming a new one which 
would result in intemperance. There is an essential difference 
between giving wine or brandy to the extent of complete narcot- 
ism, or endorsing its persistent use until one's patient is in a state 
of chronic alcholism, and the judicious and temporary employment 
of it as an available stimulus in an emergency. And let me tell 
you that there is not one-hundreth part the danger of our making 
drunkards of women that there is of making topers of men. 

The exercise should be regulated most carefully. Many women 
become fatigued almost beyond measure who, strictly speaking, 

take little or no exercise. With the majority 

Proper exercise. 

of these persons the fault is not that their time 
is not occupied, but that they lack the stimulus and benefit of 



ON THE DISEASES OF WOMEN. 311 

variety of occupation. Their house-life is a species of tread-mill 
round of work and worry, with little or no change whatever. 
What this class needs is diversion, a combination of mental and 
physical exercise that shall keep all their faculties in healthful 
play. If a woman wears out her nervous energies in household 
drudgery, you must prescribe a change of habit, and season her 
cares with a little of the spice of the outside world. Fresh air 
and sunlight, society, travel, music, literature, or an additional 
servant may be useful ingredients in your prescription. 

Among what are called the " better classes," with whom life is 
a listless, perpetual holiday, a predisposition to hysteria is fre- 
quently nurtured or acquired. With many 

Hysteria among the .i -\ /» r\ • -i • ' -\ i i 

" better classes." women the seeds oi this disorder have been 

sown in boarding-school. Boarding-house life 
and hotel life, in America, are nurseries of hysteria. This kind 
of life subjects its victims, who are without proper and constant 
employment of their time, to vicissitudes of excitement, and of 
personal experience that are inimical to health. The nervous 
systems of these women suffer most severely. Their life is an 
aimless, artificial one, with a large margin of leisure which is apt 
to be wrongly appropriated. It is almost impossible for a gifted 
and attractive young or middle-aged lady to escape the perils of 
such a home, if indeed it deserves the name. 

And, since it will not always be possible for you to locate these 
patients just as you could wish, any more than to mate them pro- 
perly, you will be forced to counteract such 

Domestic occupation. . . . 

influences in the most practicable manner. 11 
they have the means and the disposition, persuade them, if pos- 
sible, to settle in homes of their own, where proper domestic 
cares may occupy a share of their time and attention. Thousands 
of women would be cured of the hysterical tendency if they 
were blessed with comfortable homes, and removed permanently 
from the corrupting influences to which they are otherwise sub- 
jected. It is sometimes absolutely essential to remove them from 
a house in which everybody knows everybody's business, and in 
which no woman has any business. You can also accomplish a 
great deal by the exercise of a little tact in keeping these patients 
busy with something useful, instructive and profitable. One may 
perhaps become interested in a course of reading which you 



312 LECTURES, CLINICAL AND DIDACTIC, 

shall map out for her. Another might be made to forget her com- 
plaints if she were to resume her music, her 
memafhlbks. ° f pr ° per French, or her German; or to participate in 
one or another of the charitable objects and 
missions, in which some of the best women of our day are so 
much engrossed. One should see more of society, and another 
less. All need some kind of diversion, some mental occupation, 
some change which shall divert their thoughts from themselves, 
and especially from a morbid stimulation and gratification of the 
sexual appetite. 

You will sometimes have to counteract such domestic infelicities 

as, by the constant fret and friction which they induce, serve to 

keep those who are predisposed to hysteria, 

^Remove domestic infelici- always Qn ^ ^ ^ Tnig woman may b e 

cured by getting- her out of sight of her own 
servants ; and that one, if she can escape the neighborhood in 
which she is certain to see or hear something of others, men or 
women, against whom she has conceived an inveterate dislike. 

The hysterical irritability is very apt to accompany, or to be 
engrafted upon a jealous and unhappy disposition. It certainly 

is much easier to prescribe than to furnish con- 

Contentment. 

tentment to such persons, but example and pre- 
cept will accomplish wonders, even although, like the third party 
who attempts to make peace between man and wife, we some- 
times incur considerable risk in giving our advice. In all this 
you will be compelled to take a leading character in the old play 
of Tact versus Talent. And I am anxious that you shall not 
appear upon the stage of practical life as physicians without ever 
having had a rehearsal. For, in the cure of hysteria especially, 
the largest share of the work to be done may depend upon these 
common-place matters. 



ON THE DISEASES OF WOMEN. 313 



LECTURE XIX. 

treatment of hysteria (concluded). 

Gentlemen : 

From the time of the Greek midwives, who, according to Galen, 
were the first to employ the word Hysteria, its treatment has been 
divided into that proper for the paroxysm and that for the 
interval. 

When you are called to relieve a woman who is in ; ' a fit of 
hysterics," you must know what to do. First, you should be self- 
possessed, and not in a nutter. Allow nothing' 

Treatment during the fit. . "r 

to surprise you. Be cool and collected. Look 
upon the most startling developments as matters of course. Do 
not give a hasty opinion as to the result. Qualify your prognosis, 
and above all things do not be in a gloomy, despondent state of 
mind yourself. Have the patient placed in a comfortable position 
upon the bed or sofa. Let the head be slightly raised, and if 
need be, held by an assistant. Have the forehead and face bathed 
with cool or cold water, or cold compresses laid across the fore- 
head and temples. Let her have a plentiful supply of fresh air. 
If it blows from the window directly into her face, so much the 
better ; or she may be fanned by the nurse. All ligatures in the 
form of corsets and garters, etc., should be removed. The dress, 
should be thrown open at the throat especially, and only enough 
force applied to keep her from inflicting bodily injury upon herself 
and others. 

The usual restoratives consist in allowing her to smell of ordi- 
nary spirits of camphor, ammonia, musk, cologne water, chloro- 
form, ether, alcohol, vinegar, the fumes of a 

Available expedients. 

burning leather, or ol a lighted match. Sina- 
pisms and the warm foot or sitz-bath, vigorous rubbing by a strong, 
healthy person, dashing cold water upon the head or spine, the 
application of heat, electricity, and the use of brandy, coffee, cam- 



314 LECTURES, CLINICAL AND DIDACTIC, 

phor, sulphuric ether, ice water, or a solution of some salt of vale- 
rian by injection into the rectum, are among the available expedients, 
which may be tried before the patient is able to swallow. Some- 
times the paroxysm will be relieved almost immediately by firm 
pressure upon the lrypogastrium. More frequently it will pass 
away insensibly under the influence of delicate attention and quiet, 
and proper sympathy which tend to soothe and calm the excited feel- 
ings. Or it may terminate by your sending out of the room some 
person who is well enough disposed, but who is especially obnox- 
ious to the patient. 

If the fit has been induced by anger, or some fancied slight, or 
disappointment, or by mental anxiety or grief, no allusion to the 
cause or to the possible consequences of the 
attack should be permitted within hearing of 
the patient. Indeed, the greatest care should be taken to turn 
the current of conversation, if there is any in the room, into quite 
another channel, else it may prolong the disorder. Whatever is 
said should be calculated to divert her attention from herself, and 
thus indirectly to restore the will to its supremacy over the emo- 
tions, for when the will of the' patient is in league with the emo- 
tions it adds fuel to the flame to persist in telling her how very ill 
;she is. The better plan is to speak of something quite foreign to 
her present condition and surroundings, and to try to interest those 
who are present in the subject matter of conversation. This will 
be a mild means of counter-irritation, or diversion, which will 
serve to benefit the patient, who is unwittingly being toned down 
by your tact. 

It is the habit of some physicians to scold such a patient, or to 

declare contemptuously that she has " nothing but hysterics," and 

to refuse to do anything for her. This is posi- 

Don't scold. . . ° ■ . f . 

tively and unproiessionally cruel, lor, while it 
lasts, the suffering is as real as in any other disease, and the 
patient as deserving of sympathy and relief. Doctors are servants. 
And whether you are sent for in the middle of the night, or while 
at church, or at a social party, to visit an hysterical patient, you 
should carry with you as large a measure of good-nature as if you 
were going to a case of puerperal peritonitis, or of some other 
serious disease. 

Most frequently, however, the paroxysm will have ended before 



ON THE DISEASES OF WOMEN. 315 

your arrival. If she remains obstinately silent and refuses to an- 
swer your questions, give her the medicine, 

For her taciturnity. 1 1 . 

and wait until she gets ready to speak. llus 
let-alone species of indifference on your part will hasten the crisis, 
and after a fit of weeping, she will be communicative enough. 

Concerning the treatment between the paroxysms, I wish in 
the first place to insist that you shall not be misled by the inci- 
dental and irrelevant symptoms which are so common in all forms 

of hysteria. I have often thought that if it 

Treatment in the interval. . 

were possible to treat our hysterical patients 
just as we are compelled to treat infants when they are ill, that 
is, without regard to their subjective sensations, the special treat- 
ment of this disease would be greatly simplified and much more 
successful. For it is the peculiar rendering, the exaggerated esti- 
mate, the misinterpretation of the sufferings experienced, that 
will sometimes lead you to wish that such a patient was as mute 
as a child that is only a month old. 

I know that it is very difficult to discard worthless symptoms 
without at the same time eliminating some which are really valu- 
able and important, and yet, I tell you frankly 

Necessity for caution in .-i > ■ ^ , • , n , i 

the exclusion of symptoms, that, in my judgment, a majority ot the symp- 
toms, more especially those derived from the 
tongue of an hysterical patient, are of no practical significance 
whatever. You cannot depend upon them. They are compounded 
of shrewdness, cunning, trickery, deceit, a mor- 
May be too kaleidoscopic bid imagination, real suffering, and reflex irri- 

to be covered by any single ° ° 

remed >'- tions of all kinds, which confuse and confound 

us at every turn. One of my medical friends says 
that a hysterical patient is " a pathological kaleidoscope."' It is so ab- 
solutely impossible to prescribe for the totality of the symptoms 
that, in many cases of hysteria, you will be compelled to abandon 
the idea ; for when they change like the hues of the chameleon, 
and are as irreconcilable, incompatible, and contradictory, as the} r 
often are, you would need as many remedies as there are single, 
individual symptoms, and these might have to be changed several 
times daily. 

As a prospective improvement upon the ordinary unsatisfactory 
and unsuccessful method of combating hysterical symptom 3, lei 
me counsel you to direct your treatment, 1st, Against the hysteri- 



316 LECTURES, CLINICAL AND DIDACTIC, 

col diathesis, and 2d, Against the symptoms which properly belong 
to the lesion, of which the hysterical attack is 

General rules. , 7 , , . -j^.. 

either the consequence or the concomitant. Jrhysi- 
cians recognize the practical significance of the rheumatic, the 
gouty, the tuberculous, and the syphilitic diatheses. In the treat- 
ment of almost every variety of disease of which their existence 
can possibly complicate or modify the symptoms, they receive due 
consideration when we make our prescriptions. The hysterical 
predisposition is equally pronounced and equally deserving of at- 
tention. Its treatment is more decidedly hygi- 
tlTis^ hysterical dia ~ enic and prophylactic, than medicinal. It pre- 
scribes the removal, if possible, of all the causes 
which might originate or perpetuate this disorder. It regulates 
the mental and physical exercise of the patient, her habits of eat- 
ing and sleeping, her social and domestic life, and everything, in 
short, which can influence the functional operations of her ner- 
vous system. It places particular stress upon these matters in her 
case because of her constitutional bias towards hysteria. It recog- 
nizes that health cannot be restored unless the proper physiologi- 
cal conditions for its restoration and maintenance are supplied. 

A knowledge of this diathesis will sometimes aid in the selec- 

tion of our remedies. The relations of belladonna, ignatia, 

caulophvllin, agaricus, hvoscvamus, lilium tig., 

Remedies to counteract it. . 5^ " . 

gelsemmum, ether, moschus and valerian to this 
peculiar predisposition are well known to the profession. They 
are sometimes given with excellent effect as hysterical prophylac- 
tics, and may finally eradicate the disease altogether. As inter- 
current remedies they maybe equally useful. The choice between 
them will depend upon a few " characteristic," objective, cardinal 
symptoms. 

The diseases of the generative system are the most usual con- 
comitants of hysteria. Disorders of menstruation underlie a large 
proportion of the cases of this disease. Dys- 
orfe°rs ncidentmenstrualdis "menorrha3a, amenorrhea, too scanty, too copi- 
ous, irregular and too frequent menstruation may 
need to be cured before the symptoms of hysteria will disappear. 
For each of these affections you should therefore prescribe as care- 
fully as possible, taking only such note of the hysterical outgrowth 
as will enable you to counteract the predisposition of which I have 



ON THE DISEASES OF WOMEN. 317 

spoken. The chief thing is to cure the menstrual irregularity, 
after which the contingent symptoms will disappear of themselves. 
Remove the cause and the effect will cease. Cure the idiopathic 
lesion, and the sympathetic, nervous, accidental symptoms will 
vanish. 

This method of procedure will enable you to discriminate be- 
tween the legitimate symptoms, which are reliable, and those 
which are not. It will not, however, do away 
iegTdma"f;mpt" d ms? f the with the necessity for close and careful study 
of those symptoms, and a proper adaptation of 
the remedy to the cure of the menstrual difficulty. You will 
proceed to remedy that disorder, whatever it may be, with little 
or no regard to the hysterical phenomena, however noisy and 
clamorous they are. 

The same rule applies to organic disease of the ovaries, and of 
the uterus, to uterine displacements and ulceration, to hypertro- 
phy and neoplasms of the womb, to leucorrhoea, 
utSuT^tlrL^c s ° f the abortion and its consequences, to vesical and 
rectal irritation, inflammation and ulceration, 
which so frequently exist in connection with hysteria. The symp- 
toms that properly belong to these several affections are those 
which are most significant, and which will afford the real indica- 
tions for the cure of the case. There is no objection to an inter- 
current remedy for the relief and removal of a contingent delirium, 
globus or clavus hystericus, the hysterical stitch in the side, or 
the infra-mammary pain ; but your chief concern will be to recog- 
nize and cure the lesion from which so many of the symptoms are 
proliferated, but upon which they are in a sense supernumerary. 

So, also, with the gastro-alimentary, hepatic, cardiac, cerebral, 

spinal and renal difficulties which sometimes attend upon hysteria. 

These complications render it still more difficult 

Also of other organs, 

which are themselves sec- to cure. For they may be, and often are, them- 
selves secondary upon some inter-pelvic disor- 
der. Under these circumstances you will be compelled to analyze 
the symptoms, to go back to their first cause, and in selecting the 
remedy, to recognize the relative importance of the uterine and 
the ovarian symptoms. 

For example, in a case of utero-gastric or utero-cardiac disorder, 



318 LECTURES, CLINICAL AND DIDACTIC, 

the symptoms that are referable to the pelvic viscera may afford a 
more reliable guide in the treatment than the 
ca^£™dSnlemets. tero " gastric or the cardiac symptoms, separately con- 
sidered. One of my patients had an intractable 
emesis which the best chosen internal remedies failed to relieve. 
In addition to the vomiting, she had a great 
variety of hysterical symptoms, which alarmed 
her family exceedingly. Feeling confident, at last, that in her 
case the remote cause was located within the pelvis, I proposed a 
vaginal examination. The touch revealed the uterus badly pro- 
lapsed. It was replaced and kept in position, and not only did 
the vomiting cease, but the hysterical symptoms also were cured 
from that moment. 

Another lady suffered from violent attacks of palpitation of the 
heart. Her physician had decided that she really had organic dis- 
ease of the heart. These attacks of palpitation 
followed riding, walking, defecation and coitus. 
They had occurred repeatedly at intervals for more than three 
months, when I was called to see her. The nervous system had 
become so much involved that these paroxysms finally merged 
into a species of hysterical fit. Vaginal examination with the 
speculum disclosed an abrasion of almost the whole of the ante- 
rior lip of the os uteri. I applied the oleaginous collodion a few 
times, ordered her to keep off her feet, and in a fortnight the heart 
disease and its hysterical outgrowth had entirely disappeared. She 
has had no return of either affection within the last three years. 

These cases are exceptional, but they will serve to illustrate the 
importance of striking at the root of the real difficulty, when it 
is possible, instead of contenting yourselves with lopping off a 
branch here and there in the shape of an impertinent symptom, 
or class of symptoms. 

Hysteria occurring at the climacteric period, or during preg- 

nancv, labor, the parturient state, or lactation, 

^other complicating con- win need to Le treated with espe cial reference 

to these states or conditions, which are prime 
factors in the production and modification of its symptoms. 

During the winter I shall have frequent occasion to elaborate 
and apply these general rules for the treatment of Hysteria. I 
will therefore spare you the infliction of a lecture upon its special 



ON THE DISEASES OF WOMEN. 31 9 

therapeutics this morning. In the present connection it must 
suffice to remind you that it is one thing to put an end to the 
hysterical fit, by the use of such expedients as any old nurse 
could suggest and apply, and quite another thing to treat the vari- 
ous forms of this disease intelligently, thoroughly and successfully. 
For no other affection is so complicated, so enigmatical, so per- 
sistent, and so trying in every respect. And yet there is no other 
more amenable to rational, persevering and appropriate treatment.. 



IRRITABLE ULCER OF THE UTERINE CERVIX. 

Case. — Mrs. B , aged 40, has been ill for two months past. 

All her sufferings are referred to the epigastric region. She is 
subject to cramp-like pains in the pit of the stomach, which are 
sometimes so severe as to threaten her life. These paroxysms 
bear no relation to her meals, are not influenced by the variety or 
quality of her food, nor are they assuaged or aggravated in any 
manner by eating. They are quite as apt to return during the 
night as in the day. She has slight nausea, but no vomiting ; is 
very thirsty, and the bowels are costive. The tongue is pale but 
not coated, the lips are blanched, the oral mucous membrane looks 
as if it would readily become ulcerated, as in stomatitis materna. 
She is the mother of four children, the youngest of which is three 
years old. Has never had stomatitis. Has always menstruated 
regularly, but, for some months past, has observed that the flow 
is less free than formerly. She has no pelvic pain or distress of 
any kind, but is at times annoyed with a copious leucorrhcea, which 
she describes as purulent and very weakening. The discharge is 
increased by prolonged exercise, as by washing, or by walking a 
considerable distance. She has been treated for the gastric diffi- 
culty for some weeks past, but without the slightest relief. 

No physiological fact is more certain and more significant than 

the reflex relation which connects the uterus and the stomach. 

This relation is especially marked between 

ex relations of uterus t ] ie u terine cervix and the stomach. This poor 

Avoman is the victim of utero-gastric irritation 



and stomach. 



which is so decided as to make her wretched and to cause her 
a great deal of pain. But the pain and suffering are located 
exclusively in the epigastrium. From the mere symptoms which 
she has given us one would not be led to suspect any uterine com- 
plication. Even the leucorrhcea would not necessarily be due to 



"320 LECTURES, CLINICAL AND DIDACTIC, 

ulceration. It might be catarrhal, and, at her age, critical in 
character, more especially as the quantity of the menstrual flow 
\s gradually diminishing. 

In treating this class of cases in private practice it is not always 
advisable or necessary to subject the patient to an examination 
with the speculum. The better plan is to 
neIe h s3ar P } e . culumnotalways remember these reflex relations, and to try if 
possible to cure the patient without placing a 
premium on the indiscriminate use of this means of diagnosis. But 
where the disease of the stomach, the heart, or any of the more 
important viscera does not yield to well-chosen remedies, you will 
be justified in proposing to search for the remote cause within the 
pelvis. And not unfrequently you will discover a latent and 
unsuspected lesion of some kind which will be quite sufficient to 
account, not alone for the peculiar nature of the individual symp- 
toms, but also for their persistency in not yielding to treatment. 

That there may be very extensive and serious disease of the pelvic 
-organs, without a corresponding degree of suffering, indeed with- 
out the patient or her physician having sus- 
b^lT™ ksIon may pected anything of the kind, is a fact beyond 
question. It is altogether probable that the 
ulcer which some members of the class saw in this case, in 
the ante-room just now, has existed from the commencement of 
this woman's illness. I have seen examples of the kind in which 
a similar lesion must have continued for months, and even for 
years, without being recognized. Such an oversight is quite as 
inexcusable as it would be to treat a patient's throat or lungs for 
months together without ever having made a physical examination 
of the parts affected. 

The surface of these uterine ulcers, in all such as are benign and 
not malignant, or specific in character, is usually covered either 
with pus, or with a bland, somewhat gelatinous 
ive mu£us. ° l e protect " mucus, resembling the white of an egg. These 
coatings are protective, and should be removed 
very cautiously, else the free surface of the ulcer may be 
wounded, and its appearance veiy much changed. If you will 
take a bit of cotton wool, or of soft sponge in the grasp of the 
forceps, pass the instrument carefully through the speculum, and 
when it approaches the cervix uteri, give it one or two turns upon 



ON THE DISEASES OF WOMEN. 321 

Its own axis, very gently and cautiously, you can wind the mucus 
about it in such a manner as to remove it from the surface of the 
ulcer without injuring it in the least. But if you mop it off 
roughly, your examination may be of little practical advantage, 
at least in so far as the differential diagnosis of uterine ulceration 
is concerned. 

The irritable ulcer is irregular in outline, and varies in its 

depth. It looks as if it had been cut out with a " punch," 

the base thereof being considerably depressed 

Appearance of the ulcer. 

below the level 01 the mucous membrane 
covering the uterine cervix. This mucous membrane is some- 
times red, inflamed, and even ceclematous, but again, as in this 
case, it is almost as colorless as cartilage. The bottom of 
the ulcer is of a dark red cranberry hue. Sometimes its vessels 
are so surcharged with venous blood as to cause it to be almost 
black in color. The granulations are very vascular, and bleed 
upon the slightest touch. Such patients sometimes complain of 
a slight flow of blood after exercise and after coitus. 

This ulcer implies a low grade of vitality. As in the case of 
irritable ulcers located on the shin, examples of which you have 
seen in the surgical clinic, it depends upon a morbid state of the 

general constitution, and a depraved habit of 
a sign of depraved vi- £ ne patient. The digestive system is almost 

always deranged. The patient is badly nourish- 
ed. The mucous membranes elsewhere are not healthy, but 
pale, easily inflamed, and readily become ulcerated. This poor 
woman's lips and alse nasi confirm this view. They have a 
pearly, exsanguine look, and her tongue has the ragged appear- 
ance of one which has been badly ulcerated. The gums are not 
healthy, and there is every reason to suppose that the lining 
membrane of her stomach has participated to some extent in this 
tendency to inflammation and ulceration. Hence her indigestion, 
inanition, general ill-health, and uterine ulceration, which, with 
its consequent leucorrhcea, are increased sources of weakness 
and disease. 

Bat you must not suppose that this variety of ulceration is 

limited to the poorer classes of society. Indeed. 

Not limited to the poor. _ , , 

the most marked examples of this disease are 
sometimes met with among those who have "lived too welV 



322 LECTURES, CLINICAL AND DIDACTIC, 

as the phrase is. These persons have brought on indigestion, 
and a depraved state of the nutritive function by eating irregu- 
larly and immoderately, by drinking too much wine and spirits, 
and developing an irritable, nervous temperament that has 
predisposed to this species of cachexia. It sometimes follows 
excessive loss of blood, as in haemorrhage from abortion, and 
may be due to too prolonged lactation. 

Treatment. — When there is reason to believe that uterine 
ulceration proceeds from, or is perpetuated by some digestive 
derangement, it is of the first importance to 
Di C et, r etc theindigestion " correct that disorder, whatever it may be. 
For this purpose the diet should be carefully 
prescribed, such aliment being chosen as can be most readily 
digested and assimilated. Albuminous articles are preferable. 
Lean meats, milk, the white of eggs, oysters and fish in their 
season, good bread, rice and farinaceous food, afford a sufficient 
variety. Fruits will furnish the vegetable acid, which is some- 
times an excellent antidote to this cachexia. In case of indi- 
gestion, peaches, apples, pears and cherries should be cooked 
before eating them. This is especially true if they must be 
procured from the market. 

It is also desirable in this class of cases to husband the re- 
sources of the patient's system as much as possible, by closing 
any drain which may be exhausting her little 
stock of strength. Haemorrhage, too excessive 
or prolonged lactation, diarrhoea, leucorrhoea, night sweats, copious 
expectoration, or diuresis, may need to be remedied before you 
prescribe for the ulceration itself. Fresh air, sunlight, diversion 
of the mind, and the cultivation of a good morale, are as requisite 
here as elsewhere. 

The class of remedies most frequently indicated are arsenicum 
alb., nitric, muriatic or sulphuric acids, sulphur, rhus toxicoden- 
dron, baptisia tinctoria, hydrastin, and arseni- 

Internal remedies. . 

cum jod. Incidental remedies may be given 
for incidental symptoms, but we can not be very far wrong in 
prescribing the first of these for Mrs. B. She willtake a dose 
of arsenicum alb. 6th, morning and evening, and report on our 
next clinic day. 

But it is not sufficient merely to regulate the diet, the exercise. 



ON THE DISEASES OF WOMEN. 323 

and the hygienic condition and surroundings of this class of 
patients. Some kind of local treatment is 

Local treatment. nip i • r* 1 1 it 

called lor, and may, it properly selected and 
applied, assist in the cure. Although, as I have already said, 
Nature extemporizes a coating for the ulcerated cervix uteri, 
still that coating is not always sufficiently protective to prevent 
the contact of the atmosphere and of acrid discharges, which 
may serve to interrupt the healing process. And although it is 
in a measure protective, that mucus is not properly, or in any 
sense curative. Therefore we find it advisable and necessary to 
substitute this natural covering by a better one, one that shall 
serve to keep the part protected against harmful influences, and 
which is, at the same time, possessed of healing properties. You 
may sometimes apply the baptisia, calendula, hydrastin, or, if you 
prefer, the same remedy which you have ordered to be taken in- 
ternally. Simple glycerine will sometimes be sufficient. When 
either of these substances are given by injection, the vagina 
should first be syringed out thoroughly, in order to remove foreign 
matters, mucus, etc. After taking such an injection, the patient 
should lie upon the back, with the hips elevated, and without 
moving the body or shoulders for a considerable time. These 
injections may be repeated twice or thrice daily, according to cir- 
cumstances. Where the leucorrhoeal discharge is purulent and 
copious, as in this case, I prefer the calendula with glycerine. 

In this case the near approach of the climacteric may interfere 
somewhat with a prompt and radical cure of the ulceration. For, 
although all forms of uterine ulceration heal more slowly and less 
certainly at the change of life, you will find the irritable ulcer 
especially liable to become chronic, or, if healed up, to break out 
again. 

THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 

Case. — Mrs. , aged 39, has not menstruated within the 

last fourteen months. About the time the menses ceased she had 
a severe attack of dysentery, which continued four weeks. This 
was accompanied and followed by evident inflammation of the 
bladder, the vagina, and possibly, also, of the womb, from which 
she convalesced very slowly. Five months and a half later, she 
married. Her husband remained with her only two days, and 



324 LECTURES, CLINICAL AND DIDACTIC, 

then left on plea of "business in a distant State. In that period 
only two attempts were made at coitus, in neither of which did 
the male organ penetrate the vagina. She suffered extreme 
agony in these ineffectual attempts at intercourse. 

During the interval, which is now eight and a half months, the 
husband has never returned. Four months ago she observed that 
the form of her abdomen began to change, becoming more and 
move prominent in the left inguinal and hypogastric regions. 
Sometimes the tumor subsides considerably, and afterwards be- 
comes as large as before. The only unusual sensation she has 
experienced was that resembling the gurgling of a liquid, which 
seemed to pass upward from the left hypochondrium toward the 
umbilicus. The abdomen is now as large as that of one who is 
eight and a half months advanced in pregnancy, but the chief 
enlargement is upon the left side. She has had no morning sick- 
ness, no caprice of appetite, no urinary trouble, and no headache 
since she incurred the risk of becoming pregnant. The breasts 
are somewhat enlarged and tender, and the areola about the nipple 
is quite distinct. Physical examination of the abdomen by aus- 
cultation reveals a sound resembling the placental souffle, but it 
is not very decided. We have failed, after several examinations, 
to detect the foetal heart-sounds. 

Although the whole generative function is physiological, and 
does not necessarily include any morbid process whatever, still its 
contingencies are so numerous, and the changes 
which it develops within the pelvic and ab- 
dominal organs are so pronounced, and withal so similar to those 
which attend upon certain diseases, as to render the diagnosis of 
pregnancy a very delicate and difficult matter. It may involve 
the position of your patient, and others also, in society and in the 
church, loyalty to the marriage relation, and legitimacy of off- 
spring, as well as questions which are purely professional in their 
character, and which concern the proper treatment of the case in 
hand. How to decide whether a woman is or is not pregnant, is 
one of the lessons which you should learn most thoroughly. For 
nothing would so damage your reputation, as skillful practitioners, 
as to decide it wrongly. 

In many respects the case before you is a very interesting one. 
The menses have been suppressed for a long period. And, al- 
though women sometimes reach the climacteric 

Suppression of the menses. . 

before their fortieth year, there is reason to be- 
lieve that we should not attribute the arrest of function in her 



Its great importance. 



ON THE DISEASES OF WOMEN. 325 

case to this cause. If there was no uterine tumor, no development 
of the abdomen, and none of the other signs of pregnancy were 
present, we might, perhaps, charge the suppression of the accus- 
tomed flow to " change of life." If she had not suffered from dis- 
ease of the pelvic organs, and the suppression had not already 
existed before her marriage, the case would be different. As it is, 
we must remember that many other causes beside conception may 
interrupt the regularity of the menstrual function. Inflammation 
of any portion of the generative intestine, the vagina, the uterus, 
the Fallopian tubes, or of the ovaries, may cause an amenorrhea 
which shall lead us to suppose a woman to be pregnant. So also 
inflammation of the bladder, the rectum, the intestines, and even 
of the lungs, may have the same effect, directly or indirectly. 
Displacements and deviations of the womb sometimes arrest the 
flow by obliterating the canal of the uterine cervix. The pres- 
ence of polypi, fibroids, hydatids, and other tumors within that 
organ, may have the same mechanical effect. Atresia of the 
cervix, in consequence of the use of harsh astringent injections, 
or of the application of caustics, or of inflammation caused by an 
improper or ill-adjusted pessary, or of the bungling and harmful 
use of instruments in abortus or in labor at term, may also cause 
a suppression of the menses. 

Therefore, while this symptom is regarded by women themselves 

as an almost certain sign of }Dregnancy, physicians look upon it as 

equivocal, and not by any means r>ositive. We 

An uncertain sign. ... 

can not rely upon it in a given case. This woman 
has not menstruated for fourteen months. The period during which 
the arrest has continued is longer than that proper to gestation. 
Shall we therefore conclude that she is not pregnant, because she 
has passed the ninth month without being delivered of a child ? 
That would not be a safe or satisfactory conclusion. For, in some 
cases, the catamema are arrested for weeks and even for months, 
and conception takes place before they have been restored. This 
often happens with women who become pregnant again while they 
are nursing their children, and before they have begun to men- 
struate after delivery. So our patient might have had a suppres- 
sion of this flow for six months or more, and then have become 
pregnant after her marriage, and before the menses had re-ap- 
peared. 



326 LECTURES. CLINICAL AND DIDACTIC, 

With respect to this symptom, therefore, there are so many 
irregularities, complications and exceptions that it is not to be 
regarded as a positive sign of pregnancy. At best, it is only cor- 
roborative. Taken in connection with other symptoms, it may 
help to settle the diagnosis, but singly and alone it is of very little 
consequence. An additional reason why we should not place an 
exclusive dependence upon it is that we are always compelled to 
take the patient's version of the facts in the case. If she is anxious 
to have children, or, for any ulterior reason, desires to have it de- 
cided that she is pregnant, she may claim that for a given time 
she has not menstruated at all, when this is not so. Or if, on the 
other hand, she is disposed to mislead the doctor, she may insist 
that her courses are regular, and normal in every respect, when, 
in truth, they have not appeared for months. 

It is the habit of some physicians to prescribe marriage as a 
remedy for suppression of the menses, with almost a total disre- 
gard of its cause, and of the consequences of 

Marriage as a remedy for faking SUC'll advice. It is 111V duty tO Wam VOU 

suppression. O ^ J 

against this practice. For it is altogether 
wrong. Thousands of persons have been made Avretched, while 
few, very few, have been cured by it. 

In pregnancy it is not at all uncommon for the abdomen to be 
developed upon one side more than upon the other. Usually, 

however, the uterine tumor inclines to the right 

Uterine obliquities. . ^-i-i-it 

hypochondrium, lor the alleged reason that the 
rectum pushes it in that direction as the womb passes above the 
superior strait at or about the fourth month. In this case, how- 
ever, the tumor is at the left side, and has been from the first (left 
lateral obliquity). Its size and prominence, according to the 
patient's story, appear to vary somewhat, a fact which is easily 
enough explained upon the theory that there is an accompanying 
meteorism of the abdomen, which subsides of itself and recurs 
again. This would also account for the gurgling sensation, 
which is incidental, and not. in any sense, distinctive of preg- 
nancy. 

We need not discuss the negative value of the absence of morn- 
ing sickness, nausea, caprice of appetite, quickening, headache, 
toothache, vesical tenesmus, and other occasional symptoms of 
pregnancy. In many examples of gestation, they are wanting alto- 



ON THE DISEASES OF WOMEN. 327 

gether from first to last. If she has really passed the eighth month, 
ballottement would not be available. 

But the changes in the areolae about the nipples, and in the 

breasts themselves, are more significant. In pregnancy, Avhacever 

changes take place in these glands affect both 

Changes in the breasts. ^ . p ... 

breasts alike. Ihis is not true ot any disease 
to which they are subject. Consequently, when you find that both 
these organs are becoming larger, warmer, and softer, especially in 
those who have not already borne children, or been pregnant be- 
fore, or if there is a slight secretion of milk, it is a suspicious sign 
•of pregnancy. More especially is this true if the nipple is more 
erectile, vascular and granular on its exterior and tip than it has 
been, and if the circle of discoloration about it is more pronounced 
and decided. Here you have a good illustration of this subject. 
You observe the glandular follicles about the nipples are consider- 
ably enlarged, and that they pour out a quantity of fluid which 
gives the areola the appearance of having been oiled. The cellu- 
lar tissue beneath and within the nipple is in a state of turgescence. 
The discoloration about the nipple is so marked that you can see it 
across the lecture-room. This looks as if our patient were really 
pregnant, and some authorities would decide the question upon the 
evidence afforded by this single symptom. But we must look a 
little farther. 

If we could detect the foetal heart-sound, resembling the tick- 
ing of a watch beneath the pillow, we should have a positive and 

unmistakable sign of pregnancy. But this we 

The foetal heart-sound. p-it t • *i 

have tailed to elicit. And yet it may be pres- 
ent. The mere fact that we fail to detect it, is no sign that a 
woman is not pregnant ; while, if it can be heard, we knoiv that 
she is enceinte. It is not safe, however, to depend upon a single 
examination in a case of this kind. For you may imagine that 
you hear it when you do not, or it nia}^ be impossible to hear it to- 
day, and the easiest thing in the world to note it to-morrow. 

The uterine souffle is so frequent an accompaniment of ab- 
dominal and uterine tumors, aneurism, etc., as not to afford any 
reliable criterion of the pregnant state. At best 

The uterine souffle. . 

it is only a confirmatory sign, which may be 

classed as a probable, but not as a positive symptom of pregnancy. 

There is still another means of exploration that, in a case so ad- 



328 LECTURES, CLINICAL AND DIDACTIC, 

vanced as the one before us, may help to settle the diagnosis of 
pregnancy. If this woman really conceived 
eistfit and a-half months aaro, the changes which 



Changes in the cervix. 



& 



have taken place in the uterine cervix should be quite marked 
and decisive. And so I find them to be. The neck of the womb 
is shortened and almost obliterated, soft, somewhat patulous — 
although she is a primipara — and in such a condition as can only 
attend upon gestation. 

This, therefore, enables us to decide that Mrs. is undoubt- 
edly pregnant. In reaching this conclusion, we rely upon the 
changes in the breasts, the discoloration of the areolae, the char- 
acteristic softening and shortening of the cervix uteri, the abdom- 
inal development, and the placental souffle. All of these symp- 
toms are taken collectively, and within the space of a month, at 
least, I have no doubt but that our diagnosis will be confirmed, 
(JExit the patient.') 

Some of you may have doubted the possibility of conception 
without penetration of the male organ during coitus. Numerous 
cases are recorded in which this result has followed imperfect in- 
tercourse on account of some mechanical obstacle, as an imperfo- 
rate hymen, or an inveterate vaginismus, and the like. In revolv- 
ing such doubts you have only to remember that the essential 
condition of impregnation, is that the vitalizing part of the male 
semen shall be brought into contact with the ovum of the female 
somewhere within the generative tract. The discharge of that 
semen within the vulva may, under certain circumstances and ex- 
ceptionally, produce the same result that would follow the com- 
plete act. But such cases are by no means so frequent as some 
have imagined. 



ON THE DISEASES OF WOMEN. 329 



LECTURE XX 



the sponge-tent as a means of diagnosis in diseases of 
the bladder and urethra in women. 

Gentlemen : 

Some of you are already familiar with the fact that the female 
urethra may be so dilated as to admit of the introduction of the 
index finger. You have seen me perform this operation by means 
of the dressing forceps, Atlee's uterine dilator, and the sponge- 
tent. Of late this expedient has been quite frequently resorted to 
for the removal of stone from the bladder without cutting. 

Here is a sponge-tent that I wish you to examine carefully. Ten 
minutes ago it was removed from the urethra of one of my lady 

patients, and it presents some appearances 
te £ newuseofthes P° n s e - which it is quite probable you have never 

before observed. Its base is as large as a sil- 
ver dollar. It is of unusual length, and is composed of the best 
sponge. Excepting only at its smaller extremity, it is as clean 
as if it had just been washed. There is not a shred of mucus or 
a drop of blood upon it anywhere else. At its tip, however, you 
will see a quantity of pus w T hich is slightly streaked with blood. 
My patient has been ill for some weeks with a violent, non- 
specific urethritis, Under the appropriate treatment, which I 

have already detailed to you,* the inflammation of 

the urethra was entirely cured. But there re- 
mained a frequent desire to urinate, inability to retain the urine for 
more than an hour at a time (unless she was riding in her car- 
riage), an occasional deposit of a creamy-looking matter in the 
bottom of the vessel, and more or less of vesical tenesmus. Some 
of the symptoms resembling those of stone in the bladder, and all 
of them failing to respond to the usual remedies, I determined to 

* See pace 1S1. 



330 LECTURES, CLINICAL AXD DIDACTIC, 

dilate the urethra for the purpose of further exploration. This 
was first done 1)}' means of the instruments named, and afterwards 
by the introduction of a series of long sponge-tents at intervals 
of three da}~s. Each time that I have removed the tent it has 
presented the appearance so well shown in this specimen. 

The use of the tent in this case enables me to locate the seat of 
the ulceration very definitely. I know by the appearance of the 
sponge that the urethra is in a healthy state, and that the pus 
which has been discharged with the urine came from some portion 
of the bladder. Having stretched the vesical sphincter with thi» 
dilator, so that the urine escaped freely, and afterwards intro- 
duced the tent to the same distance, by actual measurement, I am 
confident that its tip was applied to and within the neck of the 
bladder. The thick, creamy pus, which has been brought away 
by the sponge, was not sufficiently fluid to have run down from 
the cavity of the bladder, but was evidently taken up by it directly 
from the diseased surface at its neck. The distal extremity of this 
sponge looks exactly as if it had been applied to a suppurating 
ulcer on the integument. 

I am, therefore, justified in feeling as confident in the diagnosis 
of ulceration of the neck of the bladder in this case, as if I had 
seen the ulcer. Indeed this means of exploration has certain ad- 
vantages over the endoscope as applied to diseases of the urinary 
passages in the female subject. It is more simple and available. 
It does not require an especial and expensive instrument. 
It furnishes a sample of the discharge, and dilates the 
urethra so as greatly to facilitate the local application of reme- 
dies, if it shall be deemed desirable. 

There is no harm in dilating the female urethra quite rapidly. 
For this reason, and because it lessens the duration of suffering, 
we choose a freshly-made tent, one that will 
soften and expand very readily. The patient 
should be placed upon the back, with the hips brought 
to the edge of the bed. The feet may be put each in 
a chair at the side of the bed, as if you were intending 
to apply the obstetric forceps. Then take Atlee's uterine dilator, 
or the long dressing forceps, have them well oiled, or anointed 
with glycerine, or with soap from the dressing-table, introduce 
them carefully into the urethra, and separate the blades so as to 



ON THE DISEASES OF WOMEN. 331 

stretch the passage from right to left, and from above downwards. 
Upon the removal of the instrument the tent can be pushed in 
carefully and steadily, until it has reached the neck of the blad- 
der. Hold it there for a few moments until it begins to soften, 
else, being pointed and somewhat conoidal, it may be forced out 
by a sort of peristaltic spasm of the adjacent muscles. You may 
leave it within the urethra for from half an hour to one or two 
hours, but not longer. For it will soften and dilate much more 
rapidly than if it were in the canal of the uterine cervix; and 
besides, an early removal will give you a better idea of the con- 
dition of the neck of the bladder than if it were allowed to 
remain for any considerable time. It need not be carbolized. 

If the passage is very narrow, or has been inflamed, it is. better 
to begin with a small-sized tent, and afterwards to use larger ones. 
The sponge is certainly preferable to the sea-tangle, or slippery 
elm and other material, because it is less hard and irritating Avhen 
first introduced, and because it does not need to be retained so 
long in the urethra. The bladder should be emptied before be- 
ginning the operation. 

I have used the tent also in very obstinate inflammation of 

the urethra, and have thus been enabled to recognize, locate and 

treat an ulceration of its mucous membrane 

The tent in urethritis. x 

much more directly and successfully' than 1 could 
otherw ise have done. The topical employment of remedies to the 
inflamed urethra might easily be secured by means of medicated 
tents and bougies. 

In dilating the urethra for the purpose of bringing medicated 
substances and injections in contact with the neck of the bladder, 

and with the upper portion of that canal, it is 

A practical hint. ,-.,'.'. . 

best to stretch it only at its inner extremity, by 
means of one of the instruments named. This leaves it funnel- 
shaped, and, while the patient lies upon her back with the hips 
raised, secures the retention and contact of the substances injected. 
An ordinary hard-rubber intra-uterine S3'ringe will answer a bet- 
ter purpose than a more complicated one for throwing these injec- 
tions into the female urethra, and even into the bladder, when it 
is necessary. 



332 LECTURES, CLINICAL AND DIDACTIC, 



SIMPLE ULCER OF THE UTERINE CERVIX. 

Case.- — Mrs. T- -, aged 28, mother of one child, has been ill 

for six months. She complains of weakness and debility, which 
incapacitate her for her daily duties. There is a great deal of 
pain in the sacral region, dragging in the loins, and bearing-down 
sensations when she is upon her feet for any considerable time. 
Internally she feels a sense of swelling and fullness within the 
vagina, and of burning at its upper portion. At times there is 
quite a free leucorrhceal flow, which is of a bland unirritating 
character. Examination with the speculum reveals a simple ulcer 
of the size of my thumb nail, situated chiefly on the posterior lip 
of the os uteri, and extending within the orifice. 

The subjective symptoms of this, as of most other varieties of 

uterine ulceration, are not peculiar. The patient may complain 

of pain in the sacrum, the hips, the thighs, 

Subjective symptoms. . 

the coccyx, the symphysis pubis, the hypogas- 
tric, or the ovarian regions. There is a sense of weight and 
fullness, of weakness and bearing-down in the region of the 
Avomb. She has, perhaps, great lassitude, with an almost 
insuperable dislike of mental and physical exertion. Leucor- 
rhcea and painful menstruation are frequent and trouble- 
some concomitants. In some cases, as in this one, there is a 
sense of tumefaction, and of local heat in the parts affected. 
This symptom is especially tormenting after the menstrual dis- 
charge has ceased, and also after coitus. Not nnfrequently there 
is an aversion to sexual congress, and when complicated with 
vaginitis, the act is likely to be followed by a bloody discharge. 
The reflex hysterical symptoms are numerous and varied. Such 
patients are prone to be hypochondriacal, and sometimes exhibit 
strong tendencies towards insanity. 

The ob'ective local symptoms revealed by the "touch" and the 
uterine speculum are peculiar, and we must rely upon them as 

diagnostic. The ulcer, the shape of which 

Objective local symptoms. . 

is irregularly circular, may occupy one or 
both lips of the cervix, although the posterior lip is its most 
frequent seat. For this latter reason the slightly curved 
speculum is sometimes preferable in making an examination. 
The lesion sometimes extends within the os and along the 
cervical canal. On removing the accumulated secretion from the 



ON THE DISEASES OF WOMEN. 333 

orifice with, a pair of long dressing-forceps and a bit of charpie or 
cotton, and expanding the bi-valve speculum, if 3-ou use it, the 
ulcer is freely exposed. There is necessity for care in all these 
manipulations of the cervix, on account of the extreme delicacy 
of the structure implicated. This ulcer within the os and the 
canal of the cervix is sometimes the last and most difficult part 
to heal. Indeed it often happens that such cases are dismissed as 
cured, when only the mucous membrane exterior to the orifice 
has been healed. 

The simple ulcer is superficial, not excavated, and its margins 

may be irregular, wavy or stellated. In some cases its borders 

are slightly raised and cord-like to the " touch." 

Appearance of. . . 

ine color is usually scarlet, evincing a re- 
markable degree of vascularity. Sometimes however, it is of a 
dark or dusky-red hue, resembling erysipelas. This blush may ex- 
tend beyond the border of the ulcer itself. The more protracted 
the case, the darker and more livid the complexion of the ulcer. 
The surface is almost always covered with a muco-purulent secre- 
tion, which must be wiped off carefully. 

In an acute case the part looks as if a corresponding extent of 
its investing epithelium had been stripped off. Sometimes there 
is a simple erosion, which Kennedy has compared to excoriations 
of the glans penis, and to aphthous ulcers in stomatitis. The 
cervix is swollen, congested and sensitive. When the lesion has 
existed for a considerable time, it has a suppurating surface, and 
it becomes the source of an intractable and exhausting leucor- 
rhoea. At this stage the simple ulcer may degenerate into the 
fungous, or granular variety, of which we shall have more to say 
hereafter. 

The most common causes are painful, forcible and too frequent 

intercourse ; coitus during or directly after menstruation, while 

the utero-vaginal mucous membrane is very vas- 

Causes. . . . . . 

cular and sensitive to mechanical injury ; dis- 
proportion in length between the male organ and the vagina ; 
the injudicious use of astringent and harmful injections per 
vaginam ; cold ; insufficient clothing of the inferior extremities ; 
vaginitis ; and friction of the parts from walking when the uterus 
is prolapsed upon the perineum, are among the more frequent 
causes of simple ulceration of the os and cervix uteri. Tyler 



334 LECTURES, CLINICAL AND DIDACTIC, 

Smith is of opinion that the corrosive properties of the leucorrhoeal 
discharge may occasion this form of ulceration, when brought into 
contact with the surface. 

This form of uterine ulceration is especially apt to occur soon 
after marriage ; or it may be caused by too prolonged nursing. 
According to eminent authorities, among whom are Churchill, 
Bennett and Whitehead, it may result in abortion and sterility. 

The treatment proper for this variety of ulceration is consti- 
stitutional and local. The internal remedies most frequently indi- 
cated are, arsenicum alb., arsenicum jod., nitric 

Treat 'ment. 

acid, belladonna, arnica, ignatia, aurum mur., 
mix vomica, sepia, and sulphur. Incidental complications, of 
course, require intercurrent and appropriate remedies. 

The local treatment should be as soothing as possible. The 

principal indication in most cases is to prevent the contact of the 

vaginal mucus and of the leucorrhoeal discharge, 

Topical treatment. " 

and so to protect the denuded surface from the 
influence of atmospheric air as to facilitate the reproduction of the 
proper epithelial tissue. If the ulceration is of traumatic origin, 
you may prescribe vaginal injections of dilute arnica with glycerine- 
If the leucorrhcea is purulent, or muco-purulent, it may be better 
to substitute calendula for the arnica. Other topical expedients 
are injections of an infusion of flax-seed, or of dilute glycerine, 
which does not become rancid ; the direct application to the ulcer 
of a watery solution of gum tragacanth, or of a solution of loaf- 
sugar ; painting the ulcer with collodion, or with glyceroles of 
iodine, hydrastin or aloes. Latour's oleaginous collodion is prefer- 
able to the ordinary collodion, because it does not cause pain 
by its shrinking.* 

THE SEQUELAE OF ABORTION. 

This patient was brought to the Clinic by my friend, Dr. W. 
W. Wilson, whose notes of the case I will read 3^011 : 

Case. — Mrs. , aged 39, English, the mother of two children, 

has always enjoyed good health until now. She has never been 

*B. Ether sulph., grammes 400. 

Alcohol, " 100. 

Gun cotton, " 35. 

Ol. ricini, " 35. 

Mix the three first ingredients thoroughly, and when dissolved, add the castor oil. 

Apply with a camel's hair brush. 



ON THE DISEASES OE WOMEN. 335 

troubled with female weaknesses of any kind, and never aborted 
before. She became pregnant during the latter part of April, and 
by the advice of an old midwife, took vaginal injections of warm 
water twice daily, for the purpose of promoting an easy labor at 
term ! On the tenth of June (at the sixth week), she came by 
railway from Indianapolis to Chicago. The next morning after 
her arrival, not having any warm water convenient, she took an 
injection of cold water instead, and this was applied with a com- 
mon rectal syringe. The shock was such that she fainted, and in 
a few minutes aborted, everything coming away with a gush. 

A physician was called in, who arrested the flow entirely, and 
the next day she felt so well that she did the washing for the 
family. That night she was seized with cramps and great pains 
through her bod}^ and limbs. Another doctor came, who said 
that she had inflammation of the bowels, and treated her accord- 
ingly. Since that time she has had four other physicians in turn, 
one of whom treated her for neuralgia of the liver (!), another 
for dropsy, a third for enlargement of the womb, and the last for 
dyspepsia. 

I was called Aug. 31, and found her in great pain and distress, 
respiration labored, pulse 125, feverish and talking incoherently. 
The pains were paroxysmal, like those of labor, but were con- 
fined to the left ovarian region. On examination, I found the 
uterus and vagina normal, except that there was a slight, whit- 
ish discharge from the os uteri. Ordered pulsatilla 200 every two 
hours, and the local use of the extract of hamamelis. 

Sept. 1. Much easier. The pains have almost entirely ceased. 
Bell. 200 . 

Sept. 2. Still improving, but restless and cannot sleep. Con- 
tinue the belladonna, but in addition to take three doses of 
coffea 30 between 4 and 10 p.m. 

Sept. 3. Husband reports his wife better. Slept well all night. 
Continue the same remedies. 

Sept. 5. Found my patient sitting up and relatively comforta- 
ble. Bryonia 2 ° ° every three hours, and zincum valerianicum 3 
dec. a powder at night. 

Sept. 8. The menses came at 10 A. M. Says she is well, but 
very weak. China 200 every three hours. 

There is no single respect in which women differ more decidedly 

than in the readiness with which they abort. With some the 

slightest causes will induce a "mishap/' A 

Causes of abortion. . i • i • » -i • 

misstep, a rough ride m a carriage, climb- 
ing stairs, a long walk, a severe cold, coughing, sneezing, 
an attack of dysentery or diarrhoea, nausea, dysuria, a severe 



336 LECTURES, CLINICAL AND DIDACTIC, 

toothache, mental anxiety, or even jumping out of bed sud- 
denly, have been known to cause it in those who were very 
susceptible. On the other hand, there are some women, who, no 
matter what they do, or suffer, are in no possible danger of mis- 
carrying. They incur eve^ risk without the least concern, or if 
so wickedly disposed, may try every means to induce an abortion, 
but without effecting it. The former are often disappointed in 
being unable to carry their offspring to term ; but sometimes take 
advantage of their idiosyncrasy to put an end to intra-uterine de- 
velopment. The latter are often victims of their own or others' 
temerity in trying to interrupt the wonderful process of gestation, 
and thousands of them suffer the remote consequences of such 
conduct in the form of uterine diseases which are sometimes en- 
tailed upon them for life. 

But nature has thrown certain safeguards around pregnant wo- 
men which generally exempt them from harmful contingencies, and 
help them to pass through the ordeal of mater- 

dulin lera r! 0n nan°c f inJUrieS U ^J Witn ^ SS °^ d an g er an( l ™^ than VOU 

would at first suppose. As pregnancy ad- 
vances she develops a species of toleration to processes that are 
new and peculiar. She even counteracts and antidotes the mis- 
chievous interference of doctors of every grade, and nurses of all 
sorts, with her prerogatives. In this woman's case, the warm 
water injections happily did no harm. She could bear them with 
impunity. But the shock of the cold water, and especially when 
taken so soon after the journey, caused an almost instantaneous 
abortion. Perhaps she might have taken this injection at another 
time without any ill effect ; but, the probabilities are that while 
the habitual use of the warm water developed a toleration for it, 
the cold application could not be borne at all without mischievous 
results. 

I regret to say that there are physicians who do not regard an 
abortion at the early period of six weeks as an affair of the least 

consequence. They will tell you that prior 
tion1st histries ° f the Ab ° r " to quickening the embryo is not alive, and 

that there is no particular necessity for min- 
istering to its welfare or for shielding it from harm. But let 
me say, that the moment the ovum escapes from the Graafian 
follicle, that moment it ceases to be a part of the maternal organ- 



ON THE DISEASES OF WOMEN. 33T 

ism. This is as true in case of fecundation as it is in menstruation. 
Arrived in the uterine cavity, the egg is no more a part of the 
mother than is the egg of the bird when laid in its nest to await 
future development, or that of the snake when dropped into the 
grass before being fertilized. It represents a separate organization, 
which, although incapable of maintaining a separate existence, is 
as really independent as the infant at birth, or its father at forty. 
Once the conditions for conception are supplied, and the vital- 
izing portion of the semen masculinum has impressed itself upon 
the ovum somewhere along the course of the 

The embryo is alive. . . . 

generative intestine, the first step in the repro- 
ductive series has been taken. From this time forth, whatever 
imperils the integrity of that germ, implicates life ; and whoever 
intentionally intercepts the wonderful changes incident thereto, 
unless to save life, is a veritable murderer — no more and no less ! 

Whether prior or subsequent to the formation of the placenta, 
the dependence upon the mother for subsistence is substantially 
the same. No one familiar with the organization and function of 
the chorion can doubt this. The physical laws that regulate the sup- 
ply and Waste, the nutrition and detritus of germ-life, embryonic 
life, and foetal life, are identical, and there is nothing in the mode 
of their operation which could lead us to infer that from the mo- 
ment of fecundation, the whole process of intra-uterine develop- 
ment is not of the greatest importance. 

It is no argument against the vitality of the smallest embryo, 
that direct vascular and nervous attachments between it and the 
endometrium have never been demonstrated. Blood-vessels have 
never "been found in cartilages, ligaments, the epithelial tissues, 
and the epidermis. We may as well declare them inanimate for 
similar reasons. Moreover, the fact that direct means of com- 
munication between the mother's organism and the fecundated 
ovum, prior to the formation of the placenta, have not been dis- 
cover d, is not to be received as proof of their non-existence. 
Reasoning by analogy, we know that the means of preserving life 
therein are not lacking. 

The fertilized human ovum is not like the seed that has been 
wrapped in an old mummy, and left for centuries to await the con- 
ditions for its development. Its growth is steady and constant, 
progressive, physiological and positive. The qualities it has 



338 LECTURES, CLINICAL AND DIDACTIC, 

derived from either parent are preserved. The predominant 
traits of temperament and predisposition, the idiosyncrasies and 
individualities that go to make up the separate being in subse- 
quent life, are there in esse. The hereditary features, and physi- 
cal bias, the mental capacity and character, which are latent and 
undiscoverable to us, are nevertheless epitomized in the develop- 
ing germ. If, prior to quickening, the mass were inanimate 
or dead, this could not be true ; nor would it be possible, when 
two or three months had elapsed, for the mother, however imagi- 
native, to imprint such paternal characteristics as are frequently 
inherited upon her offspring. The very fact that these peculiari- 
ties are perpetuated is proof positive of constant development 
and physiological change. 

Quickening is not a reliable criterion of the vitality of the 
embryo, for the obvious reasons that it does not begin at a fixed 
and determinate period of pregnancy : that 
si % 1 iffe ing not the first ** * s frequently lacking throughout gesta- 
tion ; that it may be confounded with ab- 
normal sensations of various kinds ; and that the force of the 
impulse felt by the mother may be very strong in case of a 
weakly infant, or vice versa. It is more than possible that foetal 
movements may occur for some weeks before they are recognized 
by the mother. Auscultation of the abdomen discloses the ex- 
istence of these movements before the pulsations of the foetal 
heart, or even the placental souffle can be heard. Not long since, 
a mother told me that, after its birth, a foetus of a little more 
than two months kicked quite violently ; and at a very early 
period of gestation they have been known to breathe and cry 
when suddenly expelled the uterus. 

From my frequent allusion to abortion as an indirect cause of 
many of the diseases of women, you already have an idea of the 
importance cf this subject. For the whole 
di^ase. tion as a ° ause ° f question of its prophylaxis, the right, and 
wrong, and responsibility of it, must be set- 
tled by medical men. Nothing could be more natural than for 
a sudden and forcible interruption of the textural changes and 
sympathetic relations, peculiar to pregnancy, to result in more or 
less of disease and disorder. The ovaries, the mammary glands, 
the uterine walls, vessels and lining membrane, and the nutritive 



ON THE DISEASES OF WOMEN. 339 

and nervous systems are especially apt to suffer ; and, strange to 
say. with certain exceptions, the earlier the period of the abor- 
tion, the greater the liability to these unfortunate sequelae. 

The list of these contingent and consecutive ailments is a long 

one. It includes the different forms of ovarian inflammation, 

ovarian dropsy, every species of menstrual disor- 

Sequelas of abortion. . . . 

der, peri- and para-metntis, metro-peritonitis, 
haeinatocele, the formation of moles, hydatids, fibroids, and uterine 
polypi, uterine displacements, uterine and vaginal fistulas, subse- 
quent abortion, atresia of the cervix uteri, sterility, hysteria, dys- 
pepsia, neuralgia, leucorrhcea ; malignant diseases, as cancer, at 
the climacteric, and mania. 

Such an array of the possible consequences of abortion, whether 
accidental or induced, should lead you to make an especial effort 
to prevent it, whenever it is possible. I have placed upon the 
black-board a table of the causes of abortion, which you would 
do well to copy into your note-books, and study at your leisure : 

I. — Constitutional or Predisposing. III. — Reflex, or Exciting. 

I.— Plethora, I.— Centric : 

2.— Anamiia and Chlorosis, Emotional, as Fright, Anger, Grief,, 

3. — The Scrofulous Diathesis, etc -> 

4.— The Menstrual Molimen, Direct blows upon the head or back,, 

5.— Zymotic Diseases : Cerebro-spinal meningitis, 

Syphilis Cerebro-spinal effusion, 

Mercurialization, Hysteria and Epilepsy. 

Variola, 2.— Ecentnc 



Scarlatina, 
Diphtheria, 



Parotidean Irritation, 
Thoracic do. 



Cholera. Mammary do. 

Dental do. 

Gastric do. 

Rectal do. 

II.— Local, or Organic. Vesical and Renal Irritation, 

Vaginal Irritation, 
I.— Malformation of the Ovum. Falls > jumping, blows, etc., 

2— " of the Membrane (moles, Functional and Organic Disease of 

hydatids). . the Womb, 

3.— Placental Abnormalities : Ditto of the Ovaries, 

Mal-location of, (placenta prsevia.) Death of the Embryo, 

Organic disease of, Shock from cold injections, cold 

Detachment of, bath . et c., 

Fatty degeneration of, Genital irritation (coitus), 

Calcareous ditto. Do - do. (instrumental). 

IV. — Medicinal. 

This class includes the various emmenagogues, or oxy toxics, which have been known 
to cause the uterus to empty itself of its contents, among which are tansy, (tanacetum 
vulgare). ergot, (secale cornutum), cotton plant (gossypium herb.), quinine, cantharis, 
electricity, and some others. 



340 LECTURES, CLINICAL AND DIDACTIC, 

You could not have a better illustration of the importance of 
this subject than the history of this case affords. It is more than 
possible that, until my young friend here was called to the rescue, 
no one had an intelligent idea of this poor woman's condition. 
The first doctor who came to her, and who sealed up the flow so 
promptly, should have impressed upon her the absolute necessity 
for rest and quiet. He should have insisted upon her remaining 
in bed, with as much care, and for as long a time as if she had 
just passed through labor at term. If he had taken this precau- 
tion, and given her no medicine whatever, she would probably 
have recovered without any untoward symptoms. 

But he did nothing of the kind, and the consequence was that 
she became very ill, and, worst of all, was subjected in turn to the 
tender mercies of several other incompetent I 
in effects of wrong diag- doctors. One said that she had enteritis, 

nosis. ' 

another neuralgia of the liver (!), a third 
hypertrophy of the womb, and a fourth dyspepsia. Their diagno- 
sis was wrong, and hence their treatment could not be right. 
She grew worse instead of better. 

This brings us to the practical lesson that I wish to draw from 
the case before you. It concerns the difficulty of diagnosticating 
the diseases that may accompany or follow 
tteifquJS of abortfon. zing abortion. For I am confident that this pa- 
tient's experience at the hands of her physi- 
cians is by no means an uncommon one. In truth it is very dif- 
ficult, and sometimes quite impossible, to decide whether this or 
that class of symptoms of which women complain is or is not re- 
ferable to abortion as a cause. The perplexity is increased by our 
liability to confound it with delayed or painful menstruation, 
menorrhagia, membranous dysmenorrhoea, and by the possibility 
that the patient, if so disposed, may deceive us, by leading us to 
believe that she has miscarried when she has not, or vice versa. 
Add to this that in many cases the diseases of the womb and of 
the ovaries which follow abortion run a latent course ; or they 
may partake of just enough of the hysterical "mimicry " to counter- 
feit other diseases, as for example peritonitis, enteritis, cystitis, etc. 
A recent writer* has published the following table upon the 

* Dr. Van de Warker, in the Journal of the Gynaecological Society of Boston, vol. 
IV, pp. 297-8. 



ON THE DISEASES OE WOMEN. 



341 



differential diagnosis between spontaneous and induced abor- 
tion : — 



Instrumental Abortion, to the 
Third Month. 

:. Marked constitutional disturbance from 
the first. Rigors, fainting or collapse, 
severe pain in the hypogastrium, often 
extending over the entire abdomen, 
and marked tenderness on pressure. 



Accidental and Spontaneous Abor- 
tion, to the Third Month. 

1. Ovular abortion may occur and simulate 
dysmenorrhcea. Later ; a gradual cli- 
max of symptoms, thus : loss of appe- 
tite, depression of spirits, pain in the 
loins, weight at anus or vulva, pain in 
breasts, followed by hemorrhage and 
expulsive pains in the uterus. 

2. From accident ; sharp pain in the back, 
loins, or abdomen ; often an interval 
of a day or two, or more, and then 
pains renewed violently and bleeding. 

3 Evidence of history ; habitual abor- 
tion, previous ill-health, or plethoric 
state. 

4. Often, a history of uterine displace- 4. 
ment. 

5 As a rule the pulse rarely reaches 5. As a rule pulse from 100 to 120. 



Expulsive pains before the haemorrhage 
Pain severe in the back, and in a line 
from the umbilicus to the sacrum, pain 
and haemorrhage occurring together. 
Large clots. 

Evidence of history. Previous good 
health. Evidence of habitual abortion 
absent, or doubtful. 



6. As a rule, there are no symptoms of 6. As a rule there are always symptoms 
inflammatory complications of the of inflammatory complications, and 

uterus or the abdominal viscera. tenderness on pressure over the uterus. 

Os and cervix enlarged and extremely 
tender to the touch. 

Treatment. — In case of threatened abortion, it will become your 
duty,- whenever possible, to prevent it. If, however, delivery is 
inevitable, you must conduct it to a safe termination for the moth- 
er. But your interest in the case will not end with the expulsion 
of the embryo, or the birth of the foetus, as the case may be, any 
more than the surgeon's interest in his patient should end with 
the operation of cutting off a leg, or stitching up a wound. Suc- 
cess may depend wholly upon the after-treatment. 

First, then, as in surgical fever following bodily injuries and 
surgical operations, rest is the great remedy. A woman, the lin- 
ing membrane of whose womb has been forcibly 
torn ofT in an early abortion, perhaps, by the 
use and abuse of instruments, or whose placenta has been pre- 
maturely detached in miscarriage, is as unfit for exercise as the 
man who has but just undergone an amputation of the thigh. Un- 
der these circumstances it is as necessary and proper that the ute- 
rus should repose quietly as that the stump should not be injured 
by the patient's hobbling around. 



342 LECTURES, CLINICAL AND DIDACTIC, 

I know there are women who ignore and disregard these pre- 
cautions, and who do really escape any very serious consequences. 
But, depend upon it, these cases are exceptional. Thousands of 
them suffer and die of obscure, or more obvious, uterine disease as 
the result of a lack of care after a miscarriage. It is no uncom- 
mon thing for women to leave home on a long journey directly 
after " getting through," or even while they are in danger of 
aborting on the way. And some of you know from experience 
what it is to have such patients come to you from a neighboring 
town or city directly after an " operation," looking to the murder 
of the little innocent, has been performed. In this case the un- 
known city doctor kills the offspring, while, despite your best 
efforts, the ride and the excitement may cost the mother her life. 
The analogy between the post-partum effects of abortion and 
the sequelae of a severe injury, or surgical operation, suggests the 
use of arnica both locally and internally in these 
cases. The strong tincture may be diluted in the 
proportion of one part of the arnica to six of water, and applied by 
means of compresses over the hypogastrium and pudenda. If the 
patient flows freely, or is particularly addicted to haemorrhage, the 
water should be cold ; otherwise, if she prefers, it may be tepid 
or even warm. You can advise whatever attenuation of arnica you 
choose to be taken internally at the same time. 

A very common, and a very useful prescription, of the stereo- 
type sort, is to give aconite and arnica in hourly or less frequent 
alternation. These remedies are wonderfully 

Arnica with aconite. . . - , , . • , .in 

efficacious m warding orr the incidental lever 
and traumatic inflammation. This prescription may serve you a 
good turn in case you find it impossible to visit such patients very 
often or regularly. It should be given as soon as the delivery 
and its immediate dangers are passed. Aconite is particularly in- 
dicated if the miscarriage was caused by fright, and has been 
followed by fear and dread of fatal consequences. 

In case of the development of quasi-inflammatory symptoms, 
as in the spurious peritonitis, of which I have already spoken,* 

ovarian irritation or neuralgia, undue determi- 

Belladonna. . . . • i j_ 

nation of blood to the pelvic viscera without 
haemorrhage, excessive perturbation, unrest, and nervous irritabil- 

* See page 297. 



ON THE DISEASES OF WOMEN. 343 

ity, with more or less acute pain, local or general, I know of no 
remedy so useful as belladonna. Atropine in the third decimal 
trituration will somtimes remove these symptoms like a charm. 

Chamomilla, colocynth, ignatia, hyoscyamus, and other poly- 
chrests will be useful under appropriate indications. If the pains 
assume the character of genuine after-pains, camphora, caulophyl- 
lin, belladonna, or mix vomica, may be required. If real metri- 
tis, phlebitis, or cellulitis shall result, the case will become more 
serious, and you will need to study very closely in order to find 
the appropriate remedy or remedies. Do not forget to give due 
weight to the accidental, as well as to the emotional causes of 
these secondary disorders. But I need not repeat what I have 
already said concerning their treatment. 

If the abdomen is tympanitic, and exceedingly tender to the 

touch, order the dry, hot, bran poultice, or the application of dry 

heat by means of plates wrapped in flannels, 

Local treatment. n 

or have the abdomen covered with cotton bat- 
ting, or hot flannel. If the pain is circumscribed, and limited to 
one or the other ovarian region, it is possible that relief may follow 
a change of posture. Have the patient " change sides, " and learn 
if she cannot lie with more ease upon one than upon the other. 
Forbid cold drinks while she is suffering, and let all her clothing, 
and that of the bed, be warm and dry. The chamber should be 
well ventilated, but do not allow a draft of air to pass near or over 
the bed. Place the patient in the most favorable position for re- 
gaining her health. And, what is sometimes as important as 
anything beside, see to it that officious neighbors and nurses, (and 
doctors too,) do not swarm about your patient in your absence. 
This woman is practically cured, and I will not change the pre- 
scription ; for it is a good rule in medicine as well as in morals to 
u let well enough alone." 



344 LECTURES, CLINICAL AND DIDACTIC, 



LECTURE XXI 



CHROXIC CERVICAL ENDOMETRITIS, OR EXDO-CERVICITIS. — TJTER- 
IXE LEUCORRHCEA. 



Gextle]\iex : 

Inflammation of the mucous membrane lining the uterine cervix 
is especially interesting because of its clinical relation to what is 
commonly known as uterine leucorrhcea. This patient came under 
our care sis weeks ago. She is now almost well, and I present 
her as an illustration of the importance, nay, the absolute neces- 
sity, of a correct diagnosis as a condition of cure in some of these 
cases, and for the purpose of showing you that the simplest reme- 
dies are sometimes the most efficacious. Her clinical history, 
as recorded on her admission, is as follows: — 

Case. — Mrs. , 28 years of age, the mother of two chil- 
dren, has been an invalid for two years past. Her ill health dates 
from her last accouchement, which was normal in all respects. She, 
however, -'got up" very slowly, and was weakly during lactation. 
She still nurses her child, which is a big, hearty boy ; and being 
obliged to take the entire care of him, she holds and carries him 
most of the time. She has not menstruated since her confinement. 

She complains of aching in the loins, a dragging sensation about 
the hips, which extends to the thighs, and bearing down pains and 
pressure within the pelvis, "as if everything would be forced 
from her." This latter symptom is worse when she rises to her 
feet from the chair or couch. She also has a leucorrhceal dis- 
charge, which is thick, creamy, and sometimes more watery and 
copious. The freer this flow the greater her debility and prostra- 
tion, and the more severe and distressing the pain in the back. 
Upon arising in the morning this discharge is often so profuse as 
to cause her to be faint, to destro}^ her appetite, and to incapaci- 
tate her for her household duties. She finds it impossible to stand 
more than a few minutes at a time, and can not walk but a short 
distance without being very much fatigued. She enjoys a short 
ride, providing the carriage is easy and the road is not rough. 

At times she has a burning pain which, she thinks, is in the 



ON THE DISEASES OF WOMEN. 345 

mouth of the womb. Intercourse is almost intolerable. The 
bowels are badly constipated ; the appetite poor and capricious, 
with more or less of nausea and loathing of food, especially in the 
morning. Her eyes are so weak that she can not read or sew more 
than five or ten minutes at a time without pain, indistinct vision, 
and lachrymation. 

The touch reveals a tumefaction and tenderness of the cervix 
uteri. The womb lies very low in the pelvis. The external os 
uteri is patulous, and its lining membrane everted. A thick, albu- 
minous mucus was taken directly from the canal of the cervix and 
subjected to microscopical examination. There is no visible ulcera- 
tion, although she has been treated by three physicians for that 
disease. The neighboring organs appear to be healthy. 

I have already spoken of cervical metritis, or inflammation of 
the parenchyma of the uterine cervix.* The case before us is 
one in which the lesion is limited to the mucous membrane that 
lines its canal. It is styled cervical endo-metritis, or endo-cervi- 
citis, to distinguish it from corporeal endo-metritis, internal metri- 
tis, or inflammation of the proper uterine mucous membrane, 
which is found within the cavity of the womb. For while you 
would naturally suppose that these two affections would often co- 
exist, the fact is that they are almost as distinct and as little 
related to each other as are bronchitis and bona fide pneumonia. 

Those of you who are not practically familiar with this disease 
may be disposed to question whether such a limited extent of in- 
flammation could really induce very serious or 
™,^ ent °V he cervical persistent symptoms and ill health. The ute- 

mucous membrane. * J ir 

rine cervix is only one and a quarter to one and 
a half inches in length. But the mucous membrane that lines its 
cavity presents a very considerable surface. Its rugae, or plicated 
folds, are numerous ; it is reflected over the arbor vitse uterinus, 
and dips down into each of the little glands within the 
cervix, of which, according to Dr. Tyler Smith, there are as many 
as from two to three thousand. In an ordinary case of endo-cer- 
vicitis, therefore, a larger extent of mucous membrane is inflamed 
than you would at first have supposed possible. 

And not only is this lesion an extensive one. The necessary 
implication of the glandular apparatus develops a disorder of se- 
cretion which depletes from the patient's general 

A glandular lesion. , „ 

strength, complicates the case, adds to the sut- 

* See page 274. 



346 LECTURES, CLINICAL AND DIDACTIC, 

fering and retards the cure. Every well-marked example of endo- 
cervicitis is accompanied by a more or less copious and intractable 
leucorrlicea. And, although it does not come from the cavity of 
the womb, this discharge is commonly regarded as uterine. Hence, 
a majority of writers treat of this cervical leucorrlicea, which is a 
contingent and consequence of inflammation within the cavity 
of the cervix, and exterior to the os internum, as uterine catarrh. 
As applied to this disorder the term is a misnomer, and calculated 
to mislead. For there is as great a difference 
no^meHne ca"a?rh bcea 1S between the character of the flow in true ute- 
rine catarrh, and in proper cervical leucorrlicea, 
as there is between the rusty sputa of pneumonia and the mucoso- 
puriform secretion which is stained with blood in bronchitis. 

Labor, whether in abortion or at term, is indirectly one of the 

most powerful predisponents of cervical enclo-metritis. The 

changes which the womb undergoes after deliv- 

Predisposing causes. . ' 

ery, and which are designed, through the process 
of involution, to restore it as nearly as possible to its original size 
and form, may occur so imperfectly, or so irregularly, as to leave 
that organ in a very unnatural state. In this condition of sub- 
involution, its various tissues, including the 

A sequel of labor. . . 

mucous membrane within the cervix, are prone 
"to become inflamed. It is for this reason, as in the case before 
you, that endo-cervicitis often dates from delivery. When a pa- 
tient tells you that, since the birth of her last child, she has suf- 
fered from symptoms which are the counterpart of those of which 

Mrs. complained, you will have a strong presumptive sign 

•of her disorder. A careful examination locally will either confirm 
or disprove your suspicions. 

The scrofulous cachexia also predisposes to this form of uterine 

inflammation. It could not be otherwise, when 

Scrofulosis. 

so important a part of the secretory apparatus 
is implicated. The same is true of the return of the menstrual 
cycle. The physiological afflux of blood to the uterine cervix, 

and especially to the vascular membrane lining 

Menstruation. . . 

its cavity, may develop into a state of hyperse- 
mia, and so derange the process of nutrition as to establish a gen- 
uine inflammation. Dysmenorrhoea, too frequent, tardy, scanty, 
or irregular menstruation, tend in the same direction. 



ON THE DISEASES OF WOMEN. 847 

The tuberculous diathesis is also a powerful predisponent of cer- 
vical endo-metritis. Depraved nutrition, from whatever cause, 
too prolonged lactation, rapid child-bearing, 

Tuberculosis. ... „ _ .. i -i i • , 

hereditary feebleness ol constitution, and habit- 
ual strain of the mental faculties, if it is of a depressing character, 
belong to the same list of causes. 

My observation leads me to remark that there is still another 
cause which should be included in this category. I allude to the 

influence of what is known as a " bilious cli- 

Biliary disorders. ., TTT1 -, -,. .-, 

mate. Wherever hepatic disorders prevail to 
any considerable extent, as in malarious districts, we find a strong 
tendency to this variety of uterine inflammation. Organic and 
functional diseases of the liver embarrass the circulation of venous 
blood through the pelvic viscera.* In a climate in which every 
kind of morbid state is stamped with the impress of "biliousness," 
this cause is constantly at work, and the step from congestion to 
inflammation of the cervix uteri is so short a step that it is very 
easily taken. Multitudes of women have cervical endo-metritis 
from this indirect cause alone. In confirmation of this view we 
find that, next to the large class of scrofulous subjects who suffer 
from it, women with dark hair and complexion, and black eyes, 
that is to say, who are of a bilious temperament, have this disease 
most frequently, and in its most intractable form. This is an item 
which those of you who are to locate in the South and West will 
do well to bear in mind. 

The exciting causes of this disease are very similar to those 
which often give rise to cervical metritis. A sudden arrest of the 

menstrual flow, dysmenorrhcea, cold wet feet 

Exciting causes. ... .,,. -,-, 

and damp clothing, tight lacing and the wear- 
ing of heavy skirts that are hung at the waist, violent exercise 
at the month, too forcible and intemperate coitus, the retention 
of a portion of the secundines after a miscarriage, the use of 
harsh injections to prevent impregnation, or of harmful instru- 
ments to induce abortion, ungratified sexual desire, as in nym- 
phomania ; uterine displacements ; obstinate constipation with 
paralysis or stricture of the rectum ; ovaritis ; gonorrhoea : rough 
travel in a carriage, the cars, or upon horseback, prolonged stand- 
ing upon the feet, and the wearing of ill-adjusted pessaries, are the 

*See page 144. 



348 LECTURES, CLINTCAL AND DIDACTIC, 

most common of these causes. Exceptionally, in corporeal endo- 
metritis, there is an extension of the inflammation from the cavity 
of the womb downwards into the canal of the cervix. This 
almost never occurs, unless it be in the puerperal state, in which 
case the endo-cervicitis is a sequel of the endo-metritis proper. 
In vulvovaginitis, whether it be specific or not, the inflammation 
may finally invade the cervical canal and extend as far as the 
internal os uteri. But these cases are comparatively rare. 

A mild, and in many instances a self-limited form of cervical 

endo-metritis, is sometimes met with during the pre valence of an 

epidemic influenza. You have seen several 

From Epidemic Influenza. " ; . . . . . 

cases oi this kind m our Clmique during the 
present winter. Such attacks may be either primary or secondary. 
They sometimes alternate with catarrhal inflammation of other 
mucous passages, as, for example, the nares, the throat, and the 
bronchial tubes, and perhaps also of the alimentary mucous mem- 
brane. In women of a scrofulous, or tuberculous cachexia, as 
well as in those who are greatly debilitated from other causes, an 
incidental cervicitis of this kind is very likely to become chronic. 
The most prominent and persistent symptom (in a well marked 
case of this disease) is the leucorrhcea. It is the first abnormal- 
ity to attract the patient's attention, and the 
one above all others which a majority of prac- 
titioners are most anxious to relieve and to remedy. It usually 
begins with a slight increase of the normal healthy mucus from 
the cervix, which is observed to be most abundant a day or two 
in advance of the menstrual flow. Or it may follow menstruation, 
and continue for some days after the cessation of the catamenial 
discharge. Sometimes it is intermitting in character, being 
brought on by violent exercise or excitement at' any time during 
the intra-menstrual period. The more chronic its nature, the more 
copious and exhausting it becomes. It may be creamy, viscid, 
highly albuminous, and inspissated in character. After a longer 
or shorter period, which varies in different individuals, the dis- 
charge becomes habitual and constant. Whenever the patient 
assumes the upright posture there is a sensible escape of this 
secretion from the cervix uteri. When she arises in the morning, 
after lying in bed all night, this flow may even be profuse, as it 
was a little while ago in the case before you. If it is bloody you 



ON THE DISEASES OF WOMEN. 349 

will remark that the blood is not thoroughly mingled, or incor- 
porated with the mucus — as it would be in case of a muco- 
sanguineous discharge from the uterine cavity. 

When the follicular inflammation within the cervix uteri is 
become deep-seated and chronic, more especially if it occurs in 
scrofulous subjects, the hyper-secretion is altered in character. 
Examination with the speculum discloses a string of tenacious, 
transparent, ropy mucus, hanging from the external os uteri into 
the vagina, and in exceptional cases, even from between the labia 
rnajora. Dr. W. Tyler Smith compares the appearance of this 
secretion from the cervix to that of soft soap. " It seems as if 
the alkali of the discharge combined with the fatty and albumin- 
ous element, to form a saponaceous compound. 1 '* Farther on in 
the course of the disease,, and even although there may be no 
abrasion of the os uteri, and no ulceration, pus-corpuscles are 
added, and the discharge becomes muco-purulent. In most cases, 
however, it is puriform instead of purulent. It 

The puriform discharge. .-,t -, in* • i n •• 

is seldom that the now is acrid and excoriating 
in character, unless she has ulceration of the womb ; or the in- 
flammation is specific, as, for example, diphtheritic, or sypliilitic, in 
its nature ; or the tone of her general health is Yevy low, by 
reason of debilitating diseases, such as stomatitis materna, haem- 
orrhage, inanition, and a consequent deterioration in the quality 
of the blood. 

All of which leads to the inference that this form of leucorrhcea 
should properly be regarded as a symptom, and not as a disease 

per se. In this respect it ranks with a cough, 
S ymmom UCOrrhoea merely a a haemorrhage, a dropsy, or a diarrhoea. When 

you take the discharge directly from the os 
uteri, and examine it in the field of the microscope, it presents 
the appearance shown in this diagram. Here are cylindrical 
epithelial cells, mucus-corpuscles, pus-corpuscles, blood globules, 
and fatty particles. These are found floating in an alkaline 

plasma, which vehicle is furnished by the cer- 

fl Varying characters of the - v i ca lgl an( 3 s> JJ r . Tyler Smith observed that 

the clearness or the opacity, as well as the vis- 
cidity of the discharge, its creamy, soapy, gelatinous or ropy appear- 

* The Pathology and Treatment of Leucorrhoea, by W. Tyler Smith, M. D., etc., 
Philadelphia, 1855, page 64. 



350 LECTURES, CLINICAL AND DIDACTIC, 

ance, and indeed all of its physical characters depend upon the alka- 
linity or the acidity of the secretion with which it is mingled. The 
acid mucus secreted in the vagina changes the quality of the leu- 
corrhceal fluid poured out from the cervix uteri, as decidedly as 
it does that of the blood which escapes from the same channel in 
ordinary menstruation. I think it very important for you to 
remember this fact. 

You will not understand me to say that all cases of this form 

of leucorrhcea depend upon cervicitis. By no means. There are 

other causes, such as obliquities of the uterus, 

Cervical leucorrhcea from ^he presence of foreign growths, ulceration of 

other causes. •*- ° ° 7 

the os uteri, granular degeneration, ovaritis and 
kindred affections even more remote, and which operate in a 
reflex way, that sometimes originate and perpetuate this discharge 
by stimulating an undue activity of the glands within the cervix. 
For the present I must defer their consideration. 

The dragging sensations about and within the pelvis are not 
always so marked and severe in this form of cervical inflammation 

as they are in cervical metritis. For in endo- 

Pelvic pains and suffering. ....-, i y» i i « 

cervicitis the neck ot the womb is not neces- 
sarily so tumefied and tender ; and we find that the contingent 
distress and pain in the sacral and lumbar regions vary with 
the quantity and quality of the leucorrhceal flow, rather than 
with the size of the cervix. Something depends, however, upon 
the state of the patient's strength, the duration of the disease, 
her ability to withstand suffering, or her tendency to exag- 
gerate and overstate the kind and degree of her pain. She 
is very apt to complain of bearing down sensations, symptoms 
of prolapse, forcing of the pelvic viscera towards the vulva, and 
not infrequently of rectal aching and tenesmus whenever she 
stands upon her feet. Under these circumstances there is an 
aggravation of the symptoms from motion, pressure, coughing, or 
sitting down. 

These patients frequently complain also of burning sensations, 

which are located either within the vagina, at the mouth of the 

womb, or in the ovarian region. Sometimes 

Burning sensations. .. ° 

the cervix is so displaced and tender that inter- 
course is very painful. More rarely, however, the unnatural con- 
dition of the parts causes an increased sexual desire, which the 



ON THE DISEASES OF WOMEN. 351 

patient feels must be gratified, even though it be at the cost 
of subsequent suffering. Straining at stool, or in urination, may 
cause a flow of mucus from the cervix, and even from the vagina. 
The bowels are almost always constipated, although in some cases 
there is an alternation of constipation and diarrhoea. The bladder 
is more or less implicated, and cystitis, vesical tenesmus, dysuria 
and retention are by no means infrequent. 

Either as a cause or a consequence of the local lesion, the 

digestion is impaired, the nervous system undermined, and the 

general health borne down. Among the lower 

Constitutional effects. . 

orders especially, such patients are very 
wretched. They are martyrs to vice, ignorance and self-depend- 
ence, to their children and families, to their own improvidence,, 
and not unfrequently to the incompetency of their doctors. 

A considerable proportion of cases of endo-cervicitis are char- 
acterized by impaired vision, or rather by weakness of the eyes 

and inability to use them. This is true not 

Weakness of the eyes. . . 

alone ol inflammation ot the cervical mucous 
membrane, but of other diseases of the uterine neck, and perhaps 
of the ovaries also. For there is an inexplicable sympathy be- 
tween the inferior segment of the womb and the eyes. I have 
treated a case of incipient amaurosis which was entirely and 
promptly relieved by the removal of a small mucous polypus that 
was found hanging from the external os uteri. Women have in 
almost numberless instances complained to me of pain, aching and 
weakness of the eyes immediately after the application of even 
the mildest lotions directly to the cervix. It is not at all unusual 
for this symptom to follow copulation temporarily, and in case 
of immoderate indulgence of the sexual appetite, to become 
chronic and perhaps incurable. The patient before you had these 
symptoms in a marked degree, and just in proportion as the ute- 
rine irritation and inflammation have been relieved in her case, 
has the weakness of vision and its attendant symptoms improved. 
My friend Dr. Woodyatt, the oculist, informs me, however, that 
such symptomatic derangements of vision are apt to remain after 
the primary trouble with the uterus has been cured. 

Upon making an examination with the speculum in a case of 
endo-cervicitis, if the woman has ever been pregnant, you will 
almost certainly find the cervix uteri somewhat swollen, the os 



352 LECTUKES, CLINICAL AND DIDACTIC, 

patulous, and, if the leucorrheeal flow has been copious or long 
continued, the mucous lining of the canal ol 
sp ST ation " kh the the cervix everted. In the virgin, however, 
and in those who have never conceived, as well 
as in very mild and recent cases, the tumefaction, the relaxed and 
open os uteri, and the hernia of the cervical mucous membrane may 
be lacking, and yet other equally reliable signs may lead you to 
diagnosticate the case as one of cervical endo-metritis. In other 
words, the inflammation in this case is limited to the cervical 
canal, bounded above by the internal os, and below by the exter- 
nal os uteri. I am convinced that endo-cervicitis is much more 
common among young unmarried women than it is generally sup- 
posed to be. 

In the latter class the vaginal portion of the cervix is rarely 
inflamed. Its investing membrane is not congested, neither is it 
hot, dry, or especially tender. But in confirmed cases, occurring 
in women who have borne children, you will observe that the 
mucous membrane about and within the os uteri is in a state 
of hyperemia and of evident inflammation. The nearer the men- 
strual period the more these parts will be congested, and the more 
open and dilatable the os tineas. 

In considering the diagnosis of this disease we are led to remark 
that the most mischievous results have followed the confounding 
of inflammation with ulceration and induration 
of the neck of the womb. Dr. Bennett, for 
example, believes them to be consecutive and inseparable, and, 
therefore, treats of them as synonymous, if not absolutely identi- 
cal. Errors in diagnosis, confused ideas of disease, and the careless 
use of medical terms, are necessarily followed by harmful conse- 
quences. For they always reflect the treatment that will be 
adopted. If I were to teach you that inflammation, induration 
and ulceration are essentially one and the tame disorder, my indi- 
vidual error as a teacher would react against the welfare of your 
patients and of the community, through you, because it would set 
you upon the wrong track in therapeutics. 

Remember, therefore, that the discharge from the uterine cervix 
of such products as I have described does not 

Ulceration is incidental. . 

imply that there is necessarily any ulceration 
thereof. Take a pair of speculum forceps, such as I hold in my hand, 



ON THE DISEASES OE WOMEN. 353 

-wrap a bit of cotton about them in this manner, and pass them 

through the speculum as far as the os uteii. Let them approach 

the cervix very cautiously. Then turn them over and over, thus, 

very gently, and you will wind up and remove 

A prrctical hint. J a . J ' J . . . r 

the ftrmgy mucus just as it it were a spider s 
web. If this little manipulation is carefully performed, the free 
surface of the mucous membrane will be left exposed, and you 
will see at a glance whether you have a case of simple inflamma- 
tion or of ulceration to deal with. But if you undertake to remove 
the mucus from the diseased part without this precaution, and mop 
it away roughly, the delicate vascular surface, more especially the 
hypertrophied villi will be wounded, and the part so bathed in 
blood that you can get no very definite idea of the lesion. For 
the same reason it is best to be careful in the introduction of the 
speculum, more especially the quadri-valve and cylindrical varie- 
ties, lest }'ou injure the cervix and fail in your object. 

Now a simple abrasion of the os-uteri may be, and most fre- 
quently is, merely incidental to the endo-cervicitis. The leucor- 

rhceal discharge does not come from the denuded 

The flow not from an ul- p "I i • 1 • 1 J? • i "I • j 1 i /• 

cerated surface. suilace, but is derived irom within the canal ol 

the cervix. If, however, the ulceration is deep- 
seated, and granular in character, and especially if the granula- 
tions are exuberant, and the patient is scrofulous, a large quantity 
of pus may be secreted from the surface of the sore. 

You will be able to diagnosticate endo-cervicitis from cervical 

metritis, by the absence of febrile action, and of local tenderness, 

which almost invariably accompany the latter ; 

Diagnosis from cervical iji • i _C1 1 j? ±' 

metritis. by the existence ot a leucorrhcea, of congestion 

of the mucous membrane about and within the 
cervix, the open state of the os-uteri, the eversion instead of the 
retraction of its lining membrane, and by its relation to the scrof- 
ulous and catarrhal dyscrasise. Although these diseases are some- 
times found to coexist, yet such a complication is not frequent. 

The prognosis should be guarded. If you promise to cure such 

cases in a given length of time you may be sadly disappointed ; 

for the}'' are by nature chronic and tedious. And 

Prognosis. 

there are so many causes which, directly and 
indirectly, modify the vascularity of the part that is inflamed, and 
derange and damage its glandular function, that your best inten- 
23 



354 LECTUKES, CLINICAL AND DIDACTIC, 

tions will be thwarted and 3*0111* best prescriptions often rendered 
of no effect. Sometimes the sexual instinct and appetite of his 
patient is a sworn enemy of the physician, that overrules and 
overcomes his determination to cure her of this disease. Whether 
spontaneously aroused, or purposely stimulated, or whether it be 
gratified or repressed, the effect is to antidote and to counteract 
his efforts, to complicate the case, and to postpone the cure. 

The return of the monthly crisis multiplies the contingencies 
with which this disease is beset. So also the central and depend- 
ent position of the womb, and more especially of its neck, and its 
relation to other organs, both near and remote, all of which tend 
not only to render the attack persistent and almost perpetual, but 
to bring on relapses when it has apparently been cured. 

Treatment. — -Nothing is more common than for young physi- 
cians to claim that a few doses of this or that remedy have sufficed 
to cure a case of cervical leucorrhoea. And this 

Of speedy cures. . tip i • t ii 

independently ol sexual excitement, the monthly 
exacerbation, and all the drawbacks which are but so many obsta- 
cles in the way of their superiors in age and experience. The 
fact is, their remedies may have been properly chosen, and most 
appropriate to the case in hand, but in the nature of things it is 
ascribing too much to them to insist that they are competent to 
cure such cases so promptly and decidedly. Merely to change 
the character or the quantity of the flow, or altogether to arrest 
it, is not to perform a radical cure. For relapses are the rule and 
not the exception. The doctor may plume himself on his skill in 
its treatment, and declare his patient well again, but the next day> 
the next week, or the next month, some exciting cause which is 
contingent upon her organization, or her position in the family, or 
in society, may upset all that he supposed he had accomplished, 
and consequently she is "as bad as ever again/' 

Most of the exciting causes of endo-cervicitis are avoidable. 
It will be necessary to remove your patient from under their influ- 
ence. You will see to it that there shall be no 

Remove the cause. 

sudden interruption or derangement of men- 
struation; that her clothing is suitable and sufficient ; that her feet 
are warmly clad and dry ; that her skirts are suspended from the 
shoulders ; that there are no ligatures about her body or her limbs ; 
that she is not the victim of excessive sexual indulgence (espe- 



ON THE DISEASES OF WOMEN. 355 

cially at or near the month), of uterine displacements, constipa- 
tion, dysmenorrhea, dysuria, ovaritis, blennorrhagia, rough riding, 
wearisome exercise, or the wearing of an abominable (not abdomi- 
nal) supporter or pessary. 

Both with reference to the prophylaxis and the cure of this 
complaint, an inherent tendency to scrofulous and catarrhal in- 
flammation should receive your early and con- 

The need of nourishment. . 

stant attention. It your experience shall cor- 
respond with my own, you will find that the prime indication 
with this class of subjects is to have them sufficiently nourished, 
to bring their assimilative functions and their blood up to the 
healthy standard. In other words, you must not only stop the 
drain, whatever it may be, which is exhausting their vitality, but 
also supply them with such available nutriment as shall more 
than compensate the waste that has been going on. It may -be 
quite as difficult to select the proper diet, and to arrange all its 
details to suit each individual case, as it is to select the remedy, 
but, in my judgment, it is quite as requisite to the cure of the 
disorder. 

Milk in some form, bread and milk, cream, beef, mutton, oys- 
ters, fish, fowl, game, soups and broths of different kinds, if not 
too greasy, the whites of eggs, and malt liquors, 
may supply this need. Cod liver oil has bene- 
fited some of these cases amazingly. In others the digestion has 
been improved and the general strength fortified by the use of the 
acid phosphates. Brandy and whisky are usually interdicted, 
but sometimes a mild native wine, or the extract of malt, may be 
allowed. Condiments and coffee are often injurious, while acid 
drinks are not only grateful but useful also. 

Some of these patients will never get well while they remain 
within doors. Others need a change of scenery and surround- 
ings, and they must travel. And yet another 

Travel and exercise. . . -r» l 

class must be kept m a passive state. But how 
to fill these indications without harmful consequences is the ques- 
tion for you to decide. When you have regulated all these inci- 
dental matters, which I assure you are much less trivial in their 
bearings than they seem in their recital, the case will be more 
than " half cured," and you will be prepared to study its special 
therapeutics. 



356 LECTURES, CLINICAL AND DIDACTIC, 

Excepting for the purpose of cleanliness, vaginal injections are 

of little avail in this disorder. For unless the mucous membrane 

that covers the vaginal portion of the cervix is 

Vaginal injections. . 

also inflamed, or ulcerated, they do not reach 
the diseased part. And yet you will find that a majority of those 
who have already been under treatment for this disease have been 
in the habit of taking medicated injections of various kinds. 
With a view to clear the vagina of the unnatural discharges 
which come from the neck of the womb, to prevent their decom- 
position, and also, in case the endo-cervicitis is specific, to pre- 
vent the inoculation of the adjacent parts with the poisonous 
flow, we may prescribe injections of Castile suds, or of glycerine 
and tepid water. 

A better means of relief, however, consists in the direct appli- 
cation of pure glycerine to the inflamed cervix. This substance 

has the power of causing a free discharge of 
ceHne topical use of gly " serum from its engorged capillaries, and thus of 

removing an incidental cause which not unfre- 
quently serves of itself to perpetuate the disease. The determi- 
nation of blood to the dependent cervix, and its stasis therein, is 
a prime cause of the excessive and abnormal secretion from the 
cervical glands. If we relieve this local embarrassment of the 
circulation, it is like extracting a splinter from the flesh in a case of 
irritative fever. Moreover, the expedient is simple, available and 
harmless. It neither interferes with the use of internal remedies 
nor antidotes them. It has no injurious effect upon menstruation, 
nor does it entail any reflex or remote consequences upon other 
organs, which may or may not be implicated. During the past 
six weeks this patient has had no other treatment. We have not 
given her a grain or a drop of medicine, and yet she is almost 
well. 

A good method of applying the glycerine is to make a firm 
tampon of cotton, tie a thread about the middle of it to facilitate 

its removal, saturate it thoroughly with pure 

How to apply it. . . ? • r» 

glycerine, and introduce it into the vagina after 
the patient has retired for the night. It should be pushed up 
against the cervix and left there until morning, when it can be 
withdrawn. The removal of this tampon will be followed by a 
more or less copious discharge of a thin serum, which is the pro- 



ON THE DISEASES OE WOMEN. 357 

duct of the " insalivation, ,1 as it has been termed. This little 
operation may be repeated, according to circumstances, from one 
to three times each week during the inter-menstrual period. 

Another, and a more direct means of applying this substance is 

to take such an instrument as this, which is a flat uterine probe, 

armed with a bit of cotton-wool or soft sponge, 

Another method. . . . 1 . 

saturate it with the glycerine, introduce it into 
the cavity of the cervix and pass it as far as the internal os uteri. 
Turn it about gently, and after a few seconds it may be with- 
drawn, freshly charged with glycerine, and again introduced. 
Fortunately the open state of the external os, in almost all of 
these cases, facilitates and even suggests a resort to this topical 
means of relief. The patient should remain for a time upon her 
couch, and should not go to ride or to walk for several hours after 
the application. In very rare cases the glycerine is poisonous to 
the mucous membrane, and can not be used in the manner direct- 
ed. You should always be careful to select the best quality of 
gl} r cerine for internal use. 

If the discharge is either purulent or puriform, the tincture of 

calendula may be added to the glycerine, in the proportion of one 

drachm to two ounces each of glycerine and 

Calendula, hydrastis, etc. ,..,,-, , ,. ~ 

distilled water, and applied locally. Or the 
hydrastis, hamamelis, arnica, or baptisia, may be used in the same 
way. In exceptional cases, occurring in strumous subjects, and 
which are very chronic and intractable, one drachm of the tinct- 
ure of iodine may be mixed with two ounces of glycerine, and 
applied with a camel's hair pencil to the canal of the cervix. I 
have sometimes used the oleaginous collodion with the best pos- 
sible results. 

Although, as I have already said, in enclo-cervicitis the inter- 
nal os uteri is in most instances closed, yet because it might pos- 
sibly be agape, or readily forced open, it is not 

Intra-cervical injections. . . . , . 

sale to resort to injections thrown into the cer- 
vix, lest the fluid pass into the womb, and even into the abdo- 
minal cavity. 

No matter what the variety or the decree of the uterine dis- 
placement in this disease, every species of me- 

Pessanes. . . t i 

cnamcal support is more likely to do harm than 
good. The only pessary that I ever employ in these cases is the 



358 LECTUKES, CLINICAL AND DIDACTIC, 

saturated tampon, of which I have just spoken, which some of my 
patients wear whenever they are upon their feet. Exceptionally 
the perineal strap or pad is palliative, and will permit of moder- 
ate locomotion and of riding out into the fresh air. But the or- 
dinary supports, and especially the stem-pessaries, are absolutely 
harmful in the treatment of those uterine deviations which are in- 
cident to this form of endo-metritis. 

In very tedious cases compression of the inflamed mucous 
membrane exerts a salutary influence, not only in lessening the 
copiousness of the flow, but in curing the 
lesion upon which it depends. For this pur- 
pose the carbolized sponge tent may be introduced from time to 
time, and left in situ for some hours. Or the other varieties of 
tent may be preferred. Simpson's ebony bougies sometimes answer 
equally well. Medicated bougies and suppositories are not of any 
especial value in endo-cervicitis. Compression would, however, 
be harmful, excepting in chronic cases of this disease, and should 
always be used with caution. 

Concerning the employment of caustics in the management of 

this disease, they certainly are no better indicated than they 

would be in nasal catarrh, influenza, catarrhal 

Escharotics. ' -i -• • -i-i t 

ophthalmia, or a " cold m the head. It would 
be just as reasonable, and equally efficacious, to apply the nitrate 
of silver, or chromic acid indiscriminately, in the one case as in 
the other. Physicians succeed in curing bronchial, renal and in- 
testinal catarrh without the topical use of alum, the acetate of. 
lead, or even of carbolic acid, and why should they claim that 
a similar inflammation of the mucous membrane within the uter- 
ine cervix is not, and can not ako be responsive to milder 
means of cure ? Theoretically, the adherents of the Bennet 
school are certainly wrong in their deductions ; practically, I 
believe, they are working more mischief (unwittingly, to be sure) 
than any equal number of physicians, of whatever denomination, 
the world over. For what excuse can there be for converting a 
ease of simple endo-cervicitis into one of open ulceration of the 
os uteri, in order to cure it ? And how shall the intelligent phy- 
siologist excuse himself to his own conscience for sealing a dis- 
charge from the neck of the womb, regardless of the consequences 
that may be entailed upon his patient ? 



ON THE DISEASES OE WOMEN. 359 

I have long been of the opinion that, in the selection of the 

constitutional remedies for this form of leucorrhcea especially, the 

physical characters of the flow, as it is orcli- 

A fallacious practice. .. ^ n • -i i 

narily obtained, have been considered more im- 
portant and suggestive than the facts of the case will warrant. 
The usual mode of noting the peculiarities of the discharge which 
comes from the cervical canal is fallacious. An albuminous secre- 
tion, which is alkaline in its reaction, is subject to contact, suc- 
cussion, retention and admixture with an acid mucus in the vagina, 
which changes its properties in many respects, if it does not alter 
it entirely, after which the product is recommended to be taken 
as a criterion of the actual lesion, and a guide in the choice of the 
remedy. Under these circumstances, nothing is more natural than 
that the flow should become white, watery, milky, opaque, cheesy, 
curdy, yellowish, brownish, flesh-colored, or even greenish. And, 
since the conditions which give rise to the varying qualities of the 
ieucorrhceal flow (in endo-cervicitis, or uterine catarrh), are purely 
accidental, and contingent upon the passage of that flow through 
the vagina, I feel like insisting that they are not to be depended 
upon as therapeutical data. 

Take a parallel case. Suppose that, in nasal catarrh, the dis- 
charge were first subjected to the action of the vaginal mucus, or 
to any other acid mixture, and afterwards submitted to you as 
representing the proper pathological product itself, what kind 
of an idea would you form of the disease in question ? And sup- 
pose, farther, that a physician should insist that, after such manip- 
ulation, the color and other characters of the discharge would 
indicate the remedy, what would you think of him ? 

Now, I propose, that in order to obtain a correct idea of the 

secretion which is poured out by the cervical glands in uterine 

leucorrhcea, we should not trust to the patient's 

Rule for examination of . r . -, . . . . 1 . 

the now in cervical leu- version oi the matter, neither to our own exam- 
ination of the flow, when it has been mingled 
with the vaginal mucus, but that, in order to examine it properly, 
we should take the discharge directly from the cervix uteri itself, 
as well for curative as for diagnostic reasons. Then, as in nasal 
catarrh, we would have the original product unchanged, and what- 
ever we could learn from it that would help us to differentiate be- 
tween remedies would be much more satisfactory and trustworthy 



360 LECTURES, CLINICAL AND DIDACTIC, 

in every respect. And I do not know why a leucorrhceal secretion 
should not be thus carefully inspected from time to time, as we 
examine the sputa in pneumonia, or the urine in a case of Bright's 
disease. Moreover, it should be done in the same manner in mak- 
ing our provings. 

I apprehend that the varying qualities of a natural secretion, 
as, for example, the menstrual blood, the urine, or the perspira- 
tion, as these fluids are influenced by disease, 
abnoWdischfrge"' ^ afford a much better criterion of the structural 
and functional conditions of the organ or organs 
involved, than do the physical properties of products which, like 
the sputa, diarrhceic discharges, and the cervico-leucorrhceal flow, t 
are in themselves morbid. If this is true, they also supply us with 
a better guide in the selection of our remedies. 

The physical properties of the flow in cervical leucorrhcea are 
many of them too fickle and varying to be possessed of the prac- 
tical significance which has been ascribed to them. The leucor- 
rhcea itself is but a symptom, and to divide and subdivide it, is 
perplexing to one's patience, and sometimes too transcendental to 
be of real use. If cures have been effected (and they undoubt- 
edly have), when remedies for cervical leucorrhcea have been pre- 
scribed on these shadowy indications, the result must be attributed 
to the fact that they were accidentally suited to the relief of the 
more cardinal and essential conditions underlying those symptoms. 
We may, therefore, depend upon them only when we can not do 
better. 

In vaginal leucorrhcea, however, the thickness, thinness, tenuity, 
color and peculiar character of the discharge, are more distinctive 
and significant. If it has acrid or corrosive properties, we should 
give this clinical fact its proper interpretation. For, excepting in 
case of malignant disease of the womb, as in medullary cancer, 
cauliflower excrescence, and the like, this kind of flow never 
comes from the cervix uteri. Where both these varieties of leu- 
corrhcea co-exist, as they sometimes do, you will generally succeed 
in curing the vaginal form first, and that which depends upon 
endo-cervicitis afterwards. 

If you can trace the origin of an attack of cervical endo-metri- 
tis to " taking cold," or to an epidemic influenza, no matter what 
length of time has elapsed since the disease set in, you will do well 



ON THE DISEASES OF WOMEN. 861 

to prescribe the remedy or remedies that would have been suited 
to the primary disorder. Whatever remedy 

Practical hints. T -t i " -\ iini • r\ 

would have cured the u cold, the influenza, or 
the catarrhal fever, upon which the endo-cervicitis is secondary, 
may suffice to cure its remote effects and to help your patient out 
of her difficulty. 

Due notice must also be taken of the catarrhal dyscrasia, as it 
might be termed, and of the scrofulous and the syphilitic dia- 
theses. So, likewise, of a predisposition to biliary derangements, 
whether it be chargeable to inherent peculiarities, or to the acci- 
dental circumstances of climate, season, an improper diet, or mal- 
medication. In this climate the consideration and study of these 
utero-hepatic complications are indispensable. But above all, you 
will look for the most prominent and trustworthy indications for 
your remedies in those symptoms which are connected with and 
depend upon certain coincident derangements of ovulation, men- 
struation, and of the digestive, the respiratory, the circulatory and 
the nervous systems, and also of the bladder and the rectum. If 
you will adhere closely to this method of selecting the remedy in 
this class of cases, it will enable you to distinguish the true symp- 
toms from these which are only incidental, and perhaps fallacious. 

Thus, if the prominent symptoms complained of are referable 

to ovarian irritation, inflammation, or derangement, they might 

indicate belladonna, atropine, apis mel., colo- 

For reflex ovarian disease. . . , . 

cynth, phosphorus, alumina, platma, china, 
hamamelis, pulsatilla, zincum val., lachesis, caulophyllin, lilium 
tig., conium, podophyllin, bufo, or some kindred remedy. 

Or, if some menstrual embarrassment or difficulty gives a par- 
ticular stamp, or character, to the symptoms, it may be indispens- 
able for you to study the pathogenesis, and the 
ofmenTrua n t!o e n. tdisorders published experience of the profession with 
bovista, secale cor., sabina, alumina, ferrum 
acet., calcarea carb., lilium tig., baryta carb., sepia, pulsatilla, am- 
monium carb., phosphoric acid, senecin, cocculus, helonin, can- 
tharis, or xanthoxylum. 

For the digestive complications the more 

For utero-diejestive com- -i • • ■, .-n 

plications. common remedies are mix vomica, chamomilla, 

arsenicum alb., mercurius, graphites, lvcopod- 

ium, colocynth, veratrum alb., aloes, opium, sepia, carbo veg., 



362 LECTURES, CLINICAL AND DIDACTIC, 

collinsonia can., china, sulphur, hydrastis can., the citrate of iron 
and strychnia, kreasotum, plumbum, pulsatilla, alumina, natrum 
mur., podophyllin, sesculus hip., nitric acid, and nux moschata. 
For those which implicate respiration: phosphorus, bryonia, 
sanguinaria, calcarea phos., calcarea carb., sili- 
spiraSr^ al?m C entJ landre " cea, lycopodium, stannum, tartar emetic, lache- 
sis, hyoscyamus, drosera or dulcamara. 
For symptoms connected with the local and general circulation : 
veratrum vir., bryonia alb., stannum, apis mel., 
of\le C ciTc C ufadon dls ° rders digitalis, cactus grand., aconite, gelseminum, 
veratrum alb., naja trip., or belladonna. 
For the nervous symptoms, especially in those who are liable to 
Hysteria, almost any remedy in the Materia Medica might be re- 
quired. Most likely, however, you will find 
J^oTc^^t^ what you want under the head of hyoscyamus, 
ignatia, coffea, moschus, caulophyllin, lilium 
tig., belladonna, atropine, cocculus, gelseminum, cimicifuga, caus- 
ticum, chamomilla, agaricus muse, sulphuric ether, senecio, taran- 
tula^), Scutellaria, or cypripedium. 

If the vesical symptoms are the more painful and prominent, 
you should consult the class of remedies most frequently and com- 
monly employed in the treatment of diseases 

For utero-vesical suffering. . . 

oi the bladder and urethra. I his class includes 
cantharis, cannabis sat., dulcamara, belladonna, apis mellifica, mer- 
curius, hyoscyamus, camphora, ferrum, chimaphila umb., and the 
eupatoreum purpureum. 

When the rectal troubles predominate, we have aloes, podo- 

phyllin, nux vomica, sulphur, hamamelis, col- 

^Fortheutero-rectalsymp-^^^ ^ ^ ^ ^ ^^g hippOCasta- 

num. 
Do not understand me as recommending that these remedies 
shall be given consecutively, or without discrimination. In classi- 
fying them my object has not been to supersede 
the necessity for their differential study and 
adaptation, but to indicate the variety of symptoms which, in the 
treatment of this vexatious disorder, do really afford the most 
trustworthy guides in the selection of our means of cure. For 
almost every one of them has some especial relation to diseases 
of the uterine cervix. 



ON THE DISEASES OF WOMEN. 363 



LECTURE XXII, 



the differentiae diagnosis of ovarian dropsy. 

Gentlemen : 

I am privileged this morning to show you a case which is sup- 
posed to be one of ovarian dropsy. Two weeks ago this woman 
was sent to this hospital by my colleague, Prof. Pratt. The fol- 
lowing is her clinical history : — 

Case. — Mrs. H., aged 53, a widow, has four living children, the 
youngest of which is seventeen years old. In February, six years 
ago, she was seized with diphtheria, from which she had .almost 
recovered, when, on March 1, she had a relapse. Her stomach 
became badly disordered, and she had violent vomiting. Up to 
that time her health had been good, although for three years and 
three months, or since 1863, she had not menstruated. With this 
relapse of the diphtheria the catamenia returned, at first moder- 
ately, afterwards copiously. The flow soon became almost con- 
tinuous, averaging at least two days each week for some months 
following. Afterwards it was severe and profuse. Her physicians 
told her it was due to the "change of life," and one of them pre- 
scribed some barks and roots which arrested it for the space of two 
months, when it returned as before. She consulted other physi- 
cians, but they all were of opinion that it came from the same 
cause, and recommended her to rest and keep quiet. 

About four years ago she consulted Dr. Pratt, at which time 
the flow was occasionally very profuse. In the spring of 1868, 
three and a half years ago, she had typhoid fever, and for three 
months the flow ceased. But, when she got well of the fever, it 
came on again. From that time until now, she has never passed 
a week without it. It is passive, with occasional aggravations, 
and always affords some relief, as also does a free diuresis. 

In February last (eight months ago), she first noticed a swell- 
ing in her right side, which appeared as long as her hand, and 
about as thick. She can lie upon either side indiscriminately, but 
when, after lying upon one side for a time, she turns upon the 
other, she feels something move over to that side and settle down 



364 LECTURES, CLINICAL AND DIDACTIC, 

there. She can not eat with comfort while sitting, but must either 
stand up or lie down during her meals. Within two months the 
abdominal tumor has grown rapidly. It presses upwards against 
the diaphragm, and impedes respiration. Before that time she 
could feel the outline of the solid tumor through the abdominal 
parietes, but that is impossible now. The dyspnoea is worse on 
sitting than upon lying down. The largest measurement around 
the body and over the most prominent part of the tumor is forty- 
eight inches. Her weight is one hundred and sixty pounds, but 
she has lost flesh quite perceptibly since coming to the hospital a 
fortnight ago. 

She still has occasional attacks of vomiting, which are usually, 
but not invariably, accompanied by increased haemorrhage. Under 
these circumstances the flow is painless, but is apt to be preceded 
by more or less of nausea. 

Mrs. H. has not had a cold during her six years' illness. She 
has formerly worked very hard in-doors and out. For ten years 
past she has acted in the capacity of midwife. She has had no 
swelling of the feet, the hands, or the face. About nine years 
ago, however, just before the change of life, she did have slight 
dropsical symptoms, but they soon passed away. During her early 
menstrual life the catamenia were free, but not copious. She always 
flowed a great deal in child-bed. Each of her children cost her a 
year's illness and indisposition. She has had three miscarriages, 
each of which was brought on by slight over-exertion, as from 
carrying a pail of water. There are occasional discharges from 
the womb, which are of a yellowish, and sometimes of a reddish 
cast. 

This verbatim report is sufficient proof that the case before us 
is a complicated one. As such, it is a fitting representative of the 
class to which it belongs ; for in making out the differential diag- 
nosis of ovarian dropsy, your skill will sometimes be put to the 
severest possible test. 

While our patient is lying here so comfortably, I propose to 
teach you how to diagnosticate ovarian dropsy from ascites, from 
pregnancy, from uterine fibroids and fibro-cystic tumors of the 
womb, from physometra, distention and prolapse of the bladder, 
enlargements of the liver and spleen, and from tumors caused by 
a retention of the menses, or of fsecal matter. 

I. From Ascites. — In the great majority of cases, abdominal 
dropsy is secondary upon some pre-existing chronic disease of the 
liver, of the spleen, of some portion of the digestive tract, of the 
kidneys, or, in rare instances, of the heart or lungs. In ovarian 



ON THE DISEASES OF WOMEN. 365 

dropsy this rule is reversed, and the general ill health is the con- 
sequence of the development of the tumor. 

In ascites, if the patient lies upon her back with her knees 
drawn up, the abdominal tumor becomes flattened anteriorly, and 
" bulges," or spreads out laterally. The sides 
and flanks, as well as the front surface of the 
enlargement, except directly around the umbilicus, are dull and 
flat on percussion. Around the navel, however, there is a reso- 
nant sound in ascites. If she turns upon either side, there will 
be dullness upon that side, and resonance upon the other. But 
in ovarian dropsy the contour of the tumor is not changed when 
the patient changes her position. It is not flattened in front when 
she lies upon her back. Its margin is easily mapped out. The 
flanks are not distended. There is no dullness or bulging in the 
lumbar regions, but a resonance which is quite clear and charac- 
teristic, and which assures us that the intestines lie behind a cir- 
cumscribed sac, whatever its contents may be. This is so well 
shown in the case before you, that I am quite certain you will 
remember it as a chief means of diagnosticating ovarian dropsy 
from ascites. 

You will observe how tense and hard this swelling is. This 
also constitutes a diagnostic mark, for, in ascites 

Consistence of the tumor. „ 1 .. n • n 

the walls 01 the abdomen are either flaccid or 
elastic, and more or less relaxed ; while in ovarian dropsy they are 
as tight as if there were an extreme degree of tympanites. 

In ascites the "touch" recognizes a fluctuation in the Douglas' 
cul-de-sac, which is lacking in ovarian dropsy. In ascites, also, 

the accumulation begins at the lowest and most 

The " touch." p-iit -i«-i« 

dependent part 01 the abdomen, while m ova- 
rian dropsy the tumor usually commences in the right or the left 
hypogastrium, or in one of the iliac fossae. When it exists, ex- 
treme dropsy of the abdominal walls is almost always conjoined 
with malignant disease. Coincident oedema, especially of the feet, 
may exist from the first in ascites, but never occurs in ovarian 
dropsy except in the last stage of the disease. 

Tapping is a final means of diagnosticating between these two 
affections. Having withdrawn the serum in case 
of ovarian dropsy, we find that the solid or semi- 
solid tumor does not float out of reach as before the operation, 



366 LECTURES, CLINICAL AND DIDACTIC, 

but that it may now be quite readily examined and grasped by the 
hand through the abdominal parietes. After tapping, therefore, 
the size, shape and location of this tumor can be so well made out 
that we need not confound it with such hypertrophy of the liver, 
the spleen, or of the mesenteric glands, as might have attended 
upon ascites. 

It is important for you to remember that in ascites, after para- 
centesis, the re-accumulation of water is slow, while, after the 

evacuation of an ovarian cyst, it is much more 
C ys^. efillmg ° f the sa ° ° r rapid and persistent. In one of my patients 

who had ovarian dropsy, from whom I with- 
drew many gallons of water, the abdominal tumor was quite as 
large as ever at the end of the first week. 

In exceptional cases, however, ascites and ovarian dropsy co- 
exist, and both sets of symptoms are present at the same time in 

the same patient. The diagnosis between them 

is more difficult in case the cyst is unilocular 
than if it is multilocular, because in the former the abdominal 
enlargement is more rounded and uniform, and bears a closer 
resemblance to that of ascites. 

II. From Pregnancy. — Pregnancy is self -limited, and its gen- 
eral history is so well defined that you might suppose there would 

be little risk of confounding it with ovarian 

Frequently confounded. . . 

dropsy ; but experience proves otherwise, ior 
it has frequently happened to the surgeon to declare the patient 
ill with ovarian dropsy, when, in reality, she was pregnant, and 
upon making an abdominal section to find the foetus in utero, in- 
stead of an ovarian cyst within the cavity of the peritoneum. So 
frequent is this error in diagnosis, that it would not perhaps be 
extravagant to say that at least one-third the cases of so-called 
ovarian dropsy, in which gynaecologists are consulted, prove to be 
cases of pregnancy. 

In ovarian dropsy menstruation is sometimes arrested. The 
reflex ovarian sympathies, which involve other organs, may simu- 
late those proper to gestation. The digestive 

Parallel symptoms. . - _ X & . 

function is almost necessarily more or less im- 
paired. The mammary glands maybe developed and become ten- 
der, as in pregnancy. The breasts may fill with milk, and even 
the areolae may become quite distinct. Usually, however, in ova- 



ON THE DISEASES OF WOMEN. 367 

rian dropsy, unless botli ovaries are diseased, the menses return 
irregularly, or are too frequent and copious. Last year I was 
consulted in a case of ovarian dropsy occurring 
in a woman aged thirty-six years, who, by rea- 
son of a congenital absence of the vagina, had never menstruated. 
In the case before us we exclude pregnancy, because Mrs. H. is 
so very subject to haemorrhage, which, if she were really preg- 
nant, could only arise from mal-location, or partial detachment 
of the placenta. Moreover, her haemorrhage is of too chronic a 
nature to pertain to the period of utero-gestation. The patient's 
age will sometimes assist in diagnosticating ovarian dropsy from 
pregnancy. 

In general, we say that in pregnancy the abdominal tumor has 

some peculiarities of situation and growth which may perhaps 

serve to distinguish it from an ovarian enlarge- 

Location and growth. . . 

ment. For example, it has originally been 
intra-pelvic ; it ascends gradually or more rapidly, as the case 
may be, at about the fourth month, and its globular outline is 
easily recognized by palpation. If it deviates to either side of the 
median line, its margin is smooth and well denned. From the 
fourth until the eighth month it grows from below upwards. It 
assumes the form of a general swelling, and is never described by 
the patient asa" lump " in her side, or elsewhere. 

But we must not forget that both these affections may escape 
observation or suspicion until weeks or even months have elapsed 
before our advice is sought. Under these circumstances, we shall 
be compelled to rely upon other signs in order to separate them 
and to treat them properly. 

The "touch" may aid very greatly in the diagnosis. In preg- 
nancy, after the fifth month, and more especially in multiparas, 
the uterine cervix is considerably softened, 
bo?h a ,"a g te S s. inthecervixin swollen, and compressible, and the external 
os uteri patulous. In uncomplicated ovarian 
dropsy its shape, size and cartilaginous character remain un- 
changed. In pregnancy, at or after the fifth month, you would 
expect to find the cervix at. the superior strait, not far from the 
promontory of the sacrum. And, although it is frequently drawn 
up and either ante-flexed, or displaced toward the affected side in 
ovarian dropsy, still its location will in most cases not differ ma- 



368 LECTUKES, CLINICAL AND DIDACTIC, 

terially from that of the unimpregnated uterus. If the internal 
os uteri were open, and the finger did not come into direct contact 
Avith the membranes, the placenta, or with some part of the foetus, 
the woman could not be pregnant. The easy introduction of the 
uterine sound, and its ready passage to the fundus uteri, would 
also enable you to exclude pregnancy from the list of probabili- 
ties. But the sound should not be used unless it is manifest that, 
if the patient is pregnant, her "term 1 ' is very near. 

The uterine souffle is so equivocal a sign of pregnancy that, 
except as confirmatory, we can not place much dependence upon 
it ; for it has been found that it does not arise, 
reiTaw e utenne souffle un ~ as was once supposed, from an increased devel- 
opment of vessels, and an augmented circula- 
tion of blood at the site of the placenta and through it. In other 
words, it is not necessarily connected with the utero-placental cir- 
culation. It may be present in fibroids, in uterine cancer and 
hypertrophy, in tumors within the broad ligament, in aneurism 
of the abdominal aorta, in case of a tumor pressing upon the iliac 
arteries, in sub-involution of the womb after delivery, and also in 
ovarian enlargement with or without dropsy. 

If you are fortunate enough to detect the foetal heart-sounds, 
all doubt will be at an end. But, although this will afford 3-011 an 
unequivocal sign of pregnancy, if you can recog- 
unlquivS heart " sound nize it, it would not, however, be wise to con- 
clude that your patient was not pregnant simply 
because, after repeated trials, you failed to find it ; for it might be 
so distant, indistinct and obscure, or so modified, that you would 
not know it from other sounds. Or the position of the foetus in 
utero might be such as to render it quite impossible for you to 
hear it at all. 

In advanced pregnancy, if the position of the child is favora- 
ble, and the abdominal walls are thin, it is sometimes possible to 
recognize the head, or the extremities of the 

May co-exist. ° 

foetus, by palpation. Quickening, if it were 
genuine, would confirm this condition. And yet it has happened 
that the irregular outline of the proper ovarian tumor has been 
mistaken for that of the child ; while the movements of the foetus 
in utero are apt to be counterfeited in various ways. 

It is, therefore, more difficult to diagnosticate ovarian dropsy 



ON THE DISEASES OF WOMEN. 369 

from pregnancy than you would have supposed. Sometimes they 
co-exist. In very rare cases the dropsy is contingent upon gesta- 
tion, and disappears after delivery. 

If you can not otherwise determine the diagnosis, it will be 
best for you to proceed as in other cases where pregnancy is pos- 
sible, id est, to wait until the proper limit for 
di5L m osis as an dement ° f that condition has passed, for, ordinarily, there 
need be no haste in deciding. If the woman 
is pregnant, the tumor will not sensibly increase in size, or 
develop in an upward direction, after eight and a half months. 
When ten or twelve months have elapsed since the swelling was 
first noticed, it is tolerably certain that tbere is some kind of a 
tumor present which is independent of pregnancy as a cause. 
The only exception to this rule would be found in case of extra- 
uterine pregnancy, in which the foetus might be indefinitely 
retained. But this form of gestation is so rare as scarcely to 
deserve notice in this connection. In women, as you know, the 
natural limit for pregnancy is nine months, while the average 
duration of ovarian dropsy is about three years. 

III. From Uterine Fibroids.- — Although ovarian dropsy maybe 

accompanied by irregular menstruation, in which the flow may be 

either too frequent or too copious, or both, nev- 

Haemorrhage. . 

ertheless we can not properly say that patients 
having this form of dropsy are prone to uterine haemorrhage. In- 
deed, the dropsical and the haemorrhagic diathesis are at antipodes, 
and seldom or never exist in the same person. But the hypertro- 
phy of the muscular structure of the womb, which is pathological 
and not physiological, or which, in other words, does not pertain 
to the development of the gravid uterus, but which follows abor- 
tion or labor, or an attack of metritis, is in the majority of cases 
attended by a more or less protracted and alarming menorrhagia. 
Statistics show that only nine per cent, of the cases of ovarian 
dropsy are accompanied by uterine haemorrhage ; while as large a 
proportion of cases of uterine fibroids as seventy per cent, are 
marked by this symptom. This estimate does not include those 
extra-mural or sub-peritoneal fibroids from which such a haemor- 
rhage would be impossible. 

Whenever, therefore, you have a patient who is subject to con- 
siderable or continuous flooding, which begins and ceases without 
24 



370 LECTURES, CLINICAL AND DIDACTIC, 

any especial relation to "the month,*' and more particularly if she 
is not pregnant, and there is present a pelvic or abdominal tumor 
of considerable size, you will have reason to suspect that she has 
one or more uterine fibroids. In that case the tumor will most 
probably be due to lrypertrophy of the uterine muscular tissue, 
while the haemorrhage is a species of critical outlet or safety-valve 
for the excess of blood carried thither. 

In uterine fibroids the tumor is hard and movable. Its mobility 
is diagnostic. When you can feel that a motion is imparted to the 

whole mass by a blow from the ringer upon the 
the°urru^n e d Th"tu^r yof posterior wall of the cervix-uteri, as in ballotte- 

ment, or by introducing the uterine sound can 
lift the organ and satisfy yourself by the hand placed over the 
abdominal parietes that the entire tumor moves along with it, 
there can be little doubt of the presence of a uterine fibroid. 
Sometimes, however, it may happen in this form of neoplastic 
growth that the womb may be immovable, as it is in scirrhus 
of that organ. 

The distance to which the sound will enter the womb is also 
significant. As a rule, if it passes in more than three inches the 

uterus is said to be enlarged ; and enlargement 
cavfty gth ° f the uterine of the uterine cavity is one of the most certain 

and constant signs of these same fibroid growths. 
In uncomplicated ovarian dropsy, if the womb is sometimes elon- 
gated it is in consequence of its displacement, and of the unnatural 
pressure of the ovarian tumor upon it. The manifest changes in 
the length and size of the uterus which are present in a case of 
fibroids, do not properly belong to the clinical history of ovarian 
dropsy. In the case before us, you will observe, I pass the sound 
into the womb to the distance of six inches, by actual measure- 
ment. • 

Now this disclosure by the sound makes it necessary to remind 
you that, in very rare cases, these two affections also may co-exist. 

I am of opinion that the} r are both of them 

May co-exist. , . . 

present m this patient. Ii it were otherwise, 
the symptoms elicited a little while ago by percussion of the abdo- 
men would not be in accord with those just obtained by physical 
exploration of the womb. In our diagnosis of this form of dropsy 
from ascites, we recognized and settled the fact that this enormous 



ON THE DISEASES OE WOMEN. 371 

abdominal tumor was clue to the presence of one or more ovarian 
cysts. And now we find in the haemorrhage to which Mrs. H. has 
so long been subject, as well as in the mobility of the tumor, and 
the distance to which the sound can be passed, that there is also 
a manifest hypertrophy of the womb. My colleague, the Pro- 
fessor of Surgery, will settle the question for us presently, when 
he comes to perform the operation of ovariotomy.* 

Fibroids are of slow growth ; and so, also, are ovarian tumors, 
in the early stages of the same. But ovarian tumors sometimes 
develop rapidly from the first, or having existed 
grS. ive Iapidky ° f for some months and grown very slowly, they 
suddenly fill the abdomen and give rise to 
much suffering and discomfort. Uterine displacements and leu- 
corrhoea form a natural and almost necessary part of the history 
of fibroids, while they are generally absent in ovarian dropsy. 

IV. From Fibro-cystic growths. — Those fibroids which are 
attached to the exterior surface of the womb, and which lie be- 
neath its peritoneal investment, sometimes 

Difficulty of diagnosis. .. _ T .. . 

undergo cystic degeneration. In this case the 
tumor, which may include a number of these degenerate fibroids, 
is likely to become of such a size as to fill the abdominal cavity, 
and to be mistaken for ovarian dropsy, ascites, and even for 
pregnancy. So close is this resemblance, that in many cases the 
most skillful practitioners of this specialty have been unable to 
diagnosticate a fibrocystic from an ovarian tumor, before making 
an exploratory incision. Fortunately, however, this species of 
fibroid is comparatively rare. 

Dr. Routh's statistics show that in only three out of eighteen 
cases of fibro-cystic tumor was there any menorrhagia. Spencer 
Wells has several times diagnosed the presence 
th^foTm'of^bro'Sr' m of these fibro-cysts of the uterus by the escape 
through the trocar on paracentesis of a thin 
serum containing from five to fifteen per cent, of blood, with 
Avhich it is so intimately mixed as not to separate from it until 
after standing for some hours. 

Without enlarging upon these and other points that will help 
you to diagnosticate ovarian dropsy from fibro-cystic growths, I 

* Ovariotomy was performed in presence of the class by Prof. Danforth. The uterus 
was found to contain an intra-mural fibroid, and the abdomen a large ovarian cyst. The 
patient made a good recovery. See U. S. Med. & Surg. Journal, Vol. vii., page 191. 



372 



LECTURES, CLLNICAL AND DIDACTIC, 



will refer you to a valuable classification of the more prominent 
symptoms arranged "by Dr. Charles C. Lee, and published in the 
" N. Y. Medical Journal," vol. xiv., p. 474. 



IN OVARIAN CYSTS. 

1. Disease may occur at any period, even 
before puberty. 

2. Development rapid — usually under 
two years. 

3. Aspect of face unaltered, if the general 
health be fair. 



Fluctuation equable over the 
surface of the tumor. 



whoh 



Vaginal examination shows little dis- 
placement of the uterus — the mass 
smooth and distinct from the uterus. 



6. Mobility of the uterus independent of 
the tumor from the beginning — pelvic 
adhesions rare. 

7. Tapping causes complete collapse of 
unilocular cysts , in polycystic tumors, 
it reveals the endocysts. 

8. The fluid is clear, straw-colored, serous ; 
or viscid, clear, mucoid and albuminous. 



9. When exposed by gastrotomy the sac is 
pearly blue, or white and glistening ; 
but rarely vascular. 



IN FIBRO-CYSTS OF THE UTERUS. 

1. Scarcely ever occurs under thirty — 
generally from forty to fifty. 

2. Development slow — generally over 
two years. 

3. " Facies uterina" generally marked; 
expression anxious and dejected. 

4. Fluctuation confined to certain regions 
— generally to upper portion, while the 
lower is hard and dull. 

5. Vaginal examination shows the uterus 
high up or displaced. The mass either 
not detected or continuous with the 
uterus. 

6. Independent mobility of the womb con- 
fined to the last stage of the disease. 
Pelvic adhesions common. 

7. Tapping causes only partial collapse, 
leaving the base of the tumor firm and 
indurated. 

8. The fluid is either brownish, bloody, 
sero-purulent, or muddy ; or thin and 
yellowish, containing shreds of lymph 
or of cholesterin. 

9. The exposed sac is dark, vascular, 
thick, and frequently fasciculated with 
fibrous bands. 



V. From Physometra. — Distention of the womb with gas is 
not very likely to be confounded with ovarian dropsy. If this 
abdominal enlargement, upon which I place my hand, was due to 
such a cause, the swelling would be tympanitic on percussion over 
its whole extent, instead of dull and flat as we find it. And then, 

too, the tumefaction could be very readily re- 
moved without a resort to such a severe opera- 
tion as ovariotomy ; for we could pass a male catheter through 
the cervix uteri and discharge its contents in a very few moments. 
Physometra is always attended by more or less 
troublesome hysterical manifestations, which do 
not pertain to ovarian dropsy, and which can be dissipated by 
means of an anaesthetic. 

VI. From Distention and Prolapse of the Bladder.- — The skill- 
ful use of the female catheter and of conjoined external and in- 



Empty the uterus. 



Anaesthesia. 



ON - THE DISEASES OF WOMEN. 373 

ternal manipulation, would enable you to decide between either 
of these affections and ovarian dropsy. 

VII. From Enlargements of the Liver and Spleen. — Hypertro- 
phy of the liver is almost invariably associated with chronic dis- 
ease of that viscus. The form of dropsy that 

Physical exploration -, . . , pi-it 

attends it is that of the abdomen. When effu- 
sion has taken place into the peritoneal sac, you will recognize 
the physical signs of ascites. The margin of the enlarged liver, 
which is well defined, the absence of uterine complication, which 
is suggestive, the digestive and constitutional disorder, which are 
significant from the outset, and the general contour of the tumor, 
will help you to differentiate between enlargement of the liver and 
the presence of one or more ovarian cysts. 

So, also, with an abnormal development of the spleen. The 
constitutional symptoms which accompany it are characteristic. 
One or another of the forms of ague, and im- 
pairment of the quality of the blood, with leu- 
kemia and perhaps anaemia also, will serve to identify this lesion. 
Physical exploration of the abdomen and of the internal genera- 
tive organs will clear up the diagnosis between this species of 
tumor and ovarian dropsy. This patient's complexion, and the 
healthy color of her lips and alas nasi, lead us to exclude hyper- 
trophy of the spleen in her case. 

VIII. From Tumors caused by retention of the Menses, and of 
Faecal Matter. — The former would depend upon an imperforate 
hymen, atresia of the vagina, or of the uterine cervix, or of both 
these passages, or upon obliteration of the neck of the womb by 
some flexion or deviation of the organ, or by some foreign growth 
which served to block up its outlet. In either case the " touch," 
and the introduction of the uterine sound, would discharge the 
menstrual deposit and remove the tumor. Such an expedient 
would be useless in real ovarian dropsy. 

If there were excessive faecal accumulation, the previous history 
of the case, and, more than all beside, a careful examination of 
the tumor, would disclose the difference between it and the dis- 
ease we have before us this morning. The tumor would be hard 
and irregular, and nodulated to the feel, and could be traced along 
the course of the rectum and the colon. Emptying the bowel by 
enemata of oil, castile-suds, or of a similar solvent, would settle 
the question most effectually. 



374 LECTUKES, CLINICAL AND DIDACTIC, 



LECTURE XXIII 



AMENORRHCEA. 



Gentlemen : — 

During menstrual life, or between the ages of fourteen and forty- 
five, in this country, there are only two conditions in which the 
non-appearance of the menses can be considered 
pathological arrest of men- healthy. These are during pregnancy and 

struation. . . . . 

lactation, under other circumstances, it this 
function is not property performed the woman is not well. There 
is, therefore, a physiological and a pathological arrest of this func- 
tion. I shall speak only of the latter this morning. 

The word Amenorrhcea is used generically. It signifies a class 
of affections which are characterized by an absence of the men- 
strual flow. It includes (1) delayed menstrua- 
Definition and varieties. _ „ ., n .. _ 

tion ; (2) suppression ot the now ; and (d) re- 
tention of. the same. Let us consider these several conditions sep- 
arately. 

1. — DELAYED MENSTRUATION. 

This derangement consists in the non-performance of the men- 
strual function, in one who has arrived at the age of puberty. It 
is the emansio mensium of the old authors, and 

Emansio mensium. n -> -> • ^ 

should not be coniounded with a mere suspen- 
sion of the flow in one who has menstruated before ; neither with 
tardy menstruation in the case of women who are " irregular/' 
The young girl has reached the age of fifteen, or perhaps of 
eighteen, or twenty, but this function is not yet established. 
For some reason the first appearance of the catamenia is delayed. 
Etiology. — This irregularity is often chargeable to defective de- 
velopment. The epoch of puberty has not really arrived. She is 
yet a child. Her eye lacks expression, her 
manners are less sprightly than they should be, 
and her movements do not indicate the graceful mobility of her 



ON THE DISEASES OF WOMEN". 375 

sex. Her form and features, her carriage and bodily functions, 
do not assume their proper proportions and characteristics. She 
lacks individuality. She is masculine. Her womanly traits are 
not matured. Her health and her fecundity are implicated by 
this delay, and it becomes a serious matter to study into its causes 
and to treat it property. For not only does her welfare concern 
her individual self, but also that of her relatives, of friends, and 
of society at large. 

Delayed menstruation may be due to organic causes, as for ex- 
ample, to congenital absence of the uterus, the ovaries, the Fal- 
lopian tubes, or even of the vagina. Or it may 
be caused by inflammatory adhesions which 
have taken place at an early age in some portion of the genera- 
tive intestine, or outlet. In some cases it con- 
mSn sequela ° f inflam " scutes an idiosyncrasy. In certain families 
the establishment of this function will in every 
instance be delayed until the subject is fifteen or twenty years old. 
Its first appearance is greatly influenced by external circumstan- 
ces and surroundings, education, exercise, and associations. But 
more frequently its delay depends upon a de- 

External conditions. _ ,.. « ., . ,, ,,, T 

praved condition ot the general health. In 
many cases there is a developing dyscrasia, as for example, tuber- 
culosis, which interferes with and interrupts the coming on of the 

menses. Weakly, scrofulous, chlorotic girls are 

very liable to this form of amenorrhoea ; and 
in the great majority of cases of this kind you will note that the 
effect is likely to be taken for the cause. In all of them the gen- 
eral tone and strength are lowered, the digestion impaired, the 
blood is vitiated or impoverished, and there is atony, debility, 
and torpor of the various functions. 

Symptoms, — It is not unusual, in this form of amenorrhoea for 
the patient to complain regularly each month of the symptoms 

that usually attend upon the flow. She may 

Symptoms minus the flow . . • 

have pain in the small of the back, dragging m 
the loins, aching across the hips, weariness of the limbs, severe 
and protracted headache, malaise, anorexia, and constipation. 
These symptoms may come and go with the regularity of the 
proper " period," but without the characteristic and necessary 
discharge. Sometimes they are followed by a vicarious ha&mor- 



376 LECTUKES, CLINICAL AND DIDACTIC, 

rhage from the nose, the eyes, the ears, the lungs, the stomach, or 
the bowels. Or the proper flow may be substituted by a vicarious 
leucorrhcea. 

Delayed menstruation is especially significant in girls who are 
predisposed to any form of phthisis. In them it implies a de- 
praved cachexia, a low state of nutrition, and 

Complicated with phthisis. ,.,.,. . , , . , 

a great liability either to haemoptysis, or to the 
development of a harassing cough and hectic, which are the pre- 
cursors of serious disease of one or more of the respiratory or- 
gans. If such an one who has passed her fourteenth year with- 
out ever having menstruated, has a cough, or dyspnoea, habitual 
or frequent sore throat, hoarseness, or pain in her side, it should 
be regarded as a sign of ill health, and of impending evil, and 
measures should be immediately taken for its relief. But, you 

should remember, that great harm may be done 
"Forcing medicines " in- j n these cases by the use of "forcing: medi- 

junous. J o 

cines," which are given indiscriminately, and 
are designed to compel the flow regardless of consequences and 
of the general condition upon which the disorder depends for its 
cause. 

Diagnosis. — The diagnosis is not usually difficult. As a rule 
(to which, however, there are occasional exceptions,) conception 
before menstruation is impossible. You will, consequently, have 
less trouble in diagnosticating this form of ameiiorrhcea from preg- 
nancy than in case of suppression or of reten- 
tion. In delayed menstruation from organic 
causes there are no changes in the physical development of the 
person as in puberty. The mammae are small and rudimentary, 
the figure is gaunt and not graceful, and, therefore, the chief pre- 
sumptive, as well as the positive, signs of pregnancy are lacking. 
There are no changes in the uterine cervix, or in the size of the 
womb, and there is no abdominal tumor, as in gestation. The 
lapse of time does not alter the case, or relieve it by limitation. 
The incidental diseases are different. The monthly cycle may 
or may not be recognized in either case. 

Nevertheless, since it is possible that a girl may become preg- 
nant before ever having menstruated, or, in- 
deed, after her menses have been delayed for an 
unusual length of time, and before their final appearance, it will 



ON THE DISEASES OF WOMEN. 37T 

be best for you to qualify your diagnosis. Else it may happen, 
after all, that the cause of the delay in the catamenia has been a 
very natural and common one, and that she failed to menstruate 
because she was enceinte. A careful physical exploration would 
enable you to decide as to the presence or absence of the internal 
generative organs. 

Prognosis. — The prognosis may depend upon the existence of 
organic defects. Of course, if the uterus were absent or only im- 
perfectly developed, you could not promise a radical cure of this 
disorder of menstruation. And so also of a congenital absence 
of the ovaries, the Fallopian tubes, or of the vagina. 

Where the amenorrhcea is attributable to general ill health, or 
to local disease, the prognosis will be that of the dyscrasia, or of 
the disorder, of which in reality the absence of menstruation is 
but a sequence and a symptom. We must weigh the chances of 
recovery from scrofulosis, tuberculosis, gastro-alimentary disease, 
pleurisy, and morbid conditions and alterations of the blood. In 
other words, both with respect to the progno- 

An old and true maxim. 

sis and the treatment, we must remember that 
our patient " is not sick because she does not menstruate, but that 
she does not menstruate because she is sick." 

Treatment. — When you are consulted in a case of this kind you 
should not be inveigled into prescribing at random and indiscrim- 
inately. For many of these cases do not need 

" Let well enough alone." . T(1 ., .... ,, 

any medicine whatever, it the patient is well 
in other respects, healthy, hearty, with a good appetite, and noth- 
ing to complain of, except that, as her mother or friend will tell 
you, she "■ has seen nothing," it is best to recommend fresh air and 
plenty of it, sunshine, cheerful society of a mixed kind, travel, a 
change of scene and surroundings, diversion, to take her from 
boarding-school, and afterwards to let Nature take care of herself. 
If she remains well, (and she may do so for months or years,) she 
will be better without medicine than with it. It is time enough 
to prescribe your pellets and powders for her when she can make 
a positive complaint of suffering and ill-health. 

But if, on the contrary, the incipient signs of serious disease 

begin to crop out, you must anticipate and avert 

Anticipative treatment. , 

its iull development, r or by so doing you may, 
perhaps, ward off a threatening phthisis, or may save your pa- 



378 LECTURES, CLINICAL AND DIDACTIC, 

tient much of suffering from other diseases, and really prolong 
her life. The more chronic and complicated the original affection, 
the more difficult will be the cure, and the greater the need of 
perseverance on your part. 

2. SUPPRESSED MENSTRUATION. 

I have already said that a practical distinction should be made, 

and borne in mind, between suppression and retention of the 

menses.* This distinction is based upon the fact 

A practical distinction. . 

that menstruation, like other secretory and ex- 
cretory functions, includes two distinct processes, viz. : (1.) the 
secerning, or exhaling, of the elements of a particular fluid from 
the blood ; and (2) the pouring out, or escape of that product through 
.a natural duct or outlet. Suppression of the menses concerns the 
former process exclusively. It relates to ovulation, and to its con- 
tingent secretion from the uterine mucous membrane. It is the 
ame?iorrhe e radicale of Raciborski. When, after having been es- 
tablished and maintained for a longer or shorter period, this func- 
tion ceases for other reasons than because the woman has become 
pregnant, is nursing her child, or has passed the climacteric, (un- 
less there is an obstruction of the uterine cervix,) we say that she 
has menstrual suppression. 

Here is an interesting case, the notes of which have been taken 
by our clinical assistant, Dr. Charles Adams : — 

Case. — " About four weeks ago, Miss , aged 20, (late a 

resident of England,) applied at the College Dispensary for re- 
lief from the following symptoms : Cessation of the menses for 
the past four months, constant frontal headache, severe sacral 
pains, pains extending from the sacrum to the scapulae, occasional 
oedema of the feet and ankles, pains occasionally running down 
the limbs, vertigo on going into the open air, and obstinate con- 
stipation. At times, also, she says that she has pains from one 
hip to the other. There is no leucorrhcea, and no epistaxis. She 
states that her mother died at the age of thirty-seven years of con- 
sumption, and that eight of her own sisters have died at about 
twenty -one years of age, after a short illness, presenting the same 
(or nearly the same) symptoms that she has detailed to me. 

" As far as I can learn, there is no hereditary disease on the 
father's side. At the time of their decease, none of the eight 

* See page 57. 



OX THE DISEASES OF WOMEN. 379 

sisters who died presented any obvious symptoms of consump- . 
tion, but all of them seemed to drop off after suffering a short time 
as this patient suffers. One year ago she was cured in Bristol, 
England, of suppression of the menses of seven months' duration. 
I have prescribed for her three times without relieving any thing- 
more than the headache, and am led to believe that there must be 
a mechanical obstruction to menstruation (probably malposition of 
the uterus). Excepting a slight flush of the face, which is con- 
stant, this young woman presents no outward symptoms of inter- 
nal trouble, and were it not for her strange story, I should, per- 
haps, be suspicious of pregnancy. The remedy which relieved 
the headache was apis mellifica, but after four days that had no 
effect."' 

This patient had menstruated before, and could not therefore be 
suffering from delayed menstruation, as we have just described it. 
She may have retention of the flow, in conse- 
s U He re e s d sion ry tendency to <l u ence of some uterine deviation, as the doctor 
suspects, but it is hardly probable that each of 
her eight sisters had amenorrhcea from this cause, and all at the 
same age. The very fact that their disease developed at this par- 
ticular age renders it almost certain that they were the victims of 
tuberculosis, inherited from the mother, and that the menstrual 
suppression common to them all arose from this dyscrasia as a 
common cause. For it is not unusual for all, or nearly all, the 
daughters in a family in which phthisis is hereditary, to have this 
disease in a fatal form, when they are twenty to twenty-three 
years old. And amenorrhcea (suppressio mensium) almost always 
accompanies it. 

Suppression of the menses is more common than either of the 
other forms of amenorrhcea. The busy practitioner has to pre- 
scribe for it every day. It may come on sud- 

Course and frequency. . 

denly, or gradually and almost imperceptibly. 
The healthiest and most vigorous women, and especially those 
who are somewhat plethoric, are more likely to have it occur 
abruptly. Leuco-phlegmatic and fleshy women are prone to a 
gradual lessening and final arrest of the flow before the climac- 
teric has arrived. 

Etiology. — The causes of suppression are numerous and varied. 

Perhaps the most frequent is exposure to cold, 

Avoidable causes. 

as in getting the feet wet, walking, sitting or 
sleeping in damp clothing, improper and extreme change of dress, 



380 LECTUKES, CLINICAL AND DIDACTIC, 

as in leaving off the warm wrappings and flannels of winter, and 
substituting a thin party or ball dj?ess. Taking a cold foot- or sitz- 
bath just before or during the flow is a very common cause of sup- 
pression. Emotional states often induce it. Among them are 
fear, fright, anxiety, mental depression, excess of mental applica- 
tion, the receipt of good or bad news, or solicitude for a sick 
friend, incompatibility in the marriage relation, the worry attend- 
ant upon being a witness at court, and confinement in prison. 

Suppression is incident to attacks of fever, and of local inflam- 
mation, more particularly to ovaritis, endo-metritis, pleurisy, 
pneumonia and enteritis, to the presence of 

Incident to acute disease. . „ 

polypi, fibroids, hydatids and moles. It is often 
due to change of climate. One of my patients has had it for 
three months at a time while visiting the Rocky Mountain region. 
Another, and without any harmful consequen- 
and r Sav°ei. anse ° c imate ces, every year at the White Mountains. Tak- 
ing a sea voyage may have the same effect. A 
large proportion of the female emigrants arriving in New York 
have this form of amenorrhcea, which may persist for months 
after landing. It may also arise from chlorosis, ansemia and ple- 
thora. It is a species of idiosyncrasy with 

From an idiosyncrasy. 

certain women, now and then to have the 
function of menstruation suspended for a longer or shorter 
time, and afterwards resumed again. The slightest forms of in- 
discretion at the month may suffice to arrest 

From trivial causes. -in m i • • r> • 

the now. Taking a drink of ice-water, eating 
a little ice-cream, or indigestible food, or being too much upon 
the feet at the time, may cause it. Hewitt has had occasion 
more than once to observe " that women are liable to have the 
menstrual discharge suspended for one or two periods after first 
going to reside in a house, the staircases of which are of stone and 
uncarpeted, their previous residence having had a wooden stair- 
case only.* 

Chronic and habitual suppression is incident to advanced stages 
of consumption. In some cases, however, it characterizes the 

disease in its incipiency, and may be one of its 

From chronic disease. * t i j» i 

first symptoms. 1 ou will be consulted for the 

* The Diagnosis and Treatment of Diseases of Women, by Grailly Hewitt. London, 
1863, p. +4. 



ON THE DISEASES OF WOMEN. 381 

relief of this symptom in young women in whom it is supposed to 
be the chief and perhaps the sole cause of their ill-health. On 
proper inquiry, you ascertain that the patient has a slight, dry, hack- 
ing cough, without expectoration, but which is aggravated by ex- 
ercise. She complains of stitching, lancinating pains in the chest, 
and dyspnoea from the slightest exertion, more particularly on 
ascending the stairs. She is easily fatigued, weak, and has lost 
all relish for substantial food. She has become emaciated, has 
lost in weight, and is more pale than usual. 

These symptoms may have existed for a considerable time and 

developed insidiously, without creating any suspicion of disease 

of the lungs. But if you are observing, you 

Ins.'dious complications. . . . 

will note the order m which they made their 
appearance ; you will learn that, in the majority of cases, the pec- 
toral disorder has preceded the menstrual irregularity. In other 
words, the tubercular deposit, or the pneumonia, was idiopathic, 
while the amenorrhoea is secondary or symptomatic. 

Under these circumstances, the blood becomes deteriorated in 
quality, in consequence of its imperfect aeration and of impaired 
nutrition. All the glandular functions are im- 
dis^ase ntially a glandular plicated. The ovaries, as well as the mesen- 
teric glands, become diseased, and, if they 
perform their duty at all, do so but very irregularly and imper- 
fectly. If the blood is too poor to furnish the proper elements for 
the gastric juice, for example, it may be unfit to stimulate the 
changes that should occur in the Graafian vesicle, and which 
form an indispensable part of the function of ovulation. 

The intimate sympathy between the lungs and the ovaries, as 

well as the uterus, should not be forgotten. In every case of 

amenorrhoea, there is more or less liability to 

th£ ari °" pectoral sympa " tne development of pectoral disease. In the 

majority, the arrest of the menses predisposes 

to pulmonary haemorrhage. This is the reason why haemoptysis 

is more frequent among women t^an among men. And this also 

explains the more tardy convalescence of women from pneumonia, 

bronchitis, pleurisy, and even from pericarditis and endocarditis. 

In many cases the pectoral symptoms and those of scanty or 

suppressed menstruation alternate. Or, with each return of the 

month, there may be a serious struggle, so to speak, between the 



382 LECTURES, CLINICAL AND DIDACTIC, 

lungs and the uterus. Here is a case in point, to which. I was 
called last evening : 

Case. — Miss , aged 20, has complained since leaving board- 
ing-school, two years ago, of a harrassing cough, which never 
troubles her at any other time excepting at the month. Its com- 
ing on is the precursor of menstruation, and she is satisfied that, 
if she were to lose record of the time in which her catamenia were 
due, she would certainly be notified of the same by this cough. It 
anticipates the flow by some six to twenty-four hours, and sub- 
sides as soon as the discharge comes on. The longer the delay of 
the menses, and the more scanty the flow, the worse the cough. 

Another cause of menstrual suppression was first recognized and 
described by the late Prof. Simpson. It consists in what he 

styled super-involution of the uterus following 
uteru P s! r " involution ° f the la^or. This abnormality depends upon a species 

of marasmus, or excessive absorption of the 
uterine tissues after delivery, whereby the organ may be reduced 
to one-third of its natural size, and the proper exhalation of the 
menstrual blood from its mucous surface is rendered impossible. 
It is believed that in these cases the said textures undergo a fatty 
metamorphosis, and finally become atrophied and shrunken, as in 
the senile atrophy of those women who have passed the climac- 
teric. Such an organic change would give rise to permanent ar- 
rest of the menses, and, although comparatively rare, might follow 
any case of labor, whether premature or at term. Sub-involution, 
or deficiency of absorption, following pregnancy and parturition, 
is, however, as I shall have occasion to tell you hereafter, much 
more frequently met with. It is intimately related to the clinical 
history of uterine obliquities. 

Symptoms. — The most prominent symptom is the characteristic 
absence of the menstrual discharge, which is itself a symptom, 

and not a disease per se. All the attendant 
s y Se e ms°d S eraBged. vascular si S ns si g ni fy that some portion of the internal 

generative apparatus, more particularly the 
uterus and the ovaries, as well as the general nervous and vascu- 
lar systems, are in an abnormal condition. Weakness, lassitude, 
aching, constant fatigue, lack of interest in family or social mat- 
ters, indigestion, constipation, headache, cardiac oppression, pal- 
pitation, breathlessness, fickleness, peevishness, fugitive neuralgic 



ON THE DISEASES OF WOMEN. 383 

pains, hysterical developments of various kinds, accompany 
this arrest of function. Some women suffer from ovarian neu- 
ralgia, others from a species of uterine colic, and not a few from 
cramps or spasms of one or of all the voluntary muscles whenever 
the month, comes around and they do not flow. All, except those 
who are really plethoric, have symptoms of asthenia, sedation, 
atony, debility, and general torpor of the bodily functions. They 

become emaciated, bloodless, almost transpa- 
dS. amenorrhoeal ca " rent, and go into a decline which develops itself 

more or less rapidly according to the original state 
of their health and vitality. In brief, a species of cachexia, which 
soon becomes chronic, and perhaps incurable, follows ; and being 
complicated with general derangement and ill health, constitutes one 
of the most intractable affections to which women are liable. In ex- 
ceptional cases, however, menstruation maybe suspended for several 
months, and even for years, and finally restored without any 
harmful consequences whatever. One of the members of our 
college class last year cited the case of a woman whom he had 
known who did not menstruate from the age of 46 to 53 — seven 
years. She then menstruated once, and afterwards became preg- 
nant, and was delivered at term of a healthy living child. 

Diagnosis. — You will have more trouble to diagnosticate sup- 
pression, from pregnancy than from any and all other conditions. 

This difficulty is increased by the fact, that in 

From pregnancy. _ . . .. . 

iormmg a judgment in a given case, prior to the 
fourth month, we are left entirely at the mercy and caprice of the 
patient. She may tell us that she has incurred no possible risk of 
becoming pregnant, when such is not the truth. Or, if she is 
anxious to become a mother, may insist that nothing but concep- 
tion could have caused the arrest in her case, for she was never 
irregular before. Too exclusive a reliance upon her word may 
mislead and deceive us ; but in the first three months, there is lit- 
tle else upon which to predicate an opinion. The reflex and inci- 
dental symptoms, as nausea, loss of appetite, morning sickness, 
swelling of the breasts, are the same. Whatever changes occur 
in the uterine textures in consequence of impregnation begin in 
the body and fundus of the womb. We cannot reach or recognize 
them before the commencement of the twelfth or thirteenth week. 
Subsequent to that period, however the more unequivocal signs of 



"384 LECTURES, CLINICAL AND DIDACTIC, 

pregnancy begin to develop, and the diagnosis is more easy and 
certain. In doubtful cases, time will help }^ou 
to differentiate between a physiological sup- 
pression of this sort, and one which is in every sense pathological. 
When complicated with retention, you may even have to wait 
until the fifth or sixth, or possibly the ninth, month before you 
can say with certaint}^ whether the arrest of the menses was due 
to conception or to some accidental or morbific cause. 

In simple suppression, however, there is no permanent and con- 
tinuous abdominal development, no tumor, as in retention or in 
pregnancy. 

It will sometimes be difficult to decide whether the non-ap- 
pearance of the flow is or is not due to the "change of life." The 
age of the patient, and inquiries into her family 

From " change of life." * , , , -,. • tp i 

history may help to settle this question. If she 
is past forty, the irregularity may be due to her age, although wo- 
men do sometimes continue to menstruate much longer. 

One of my patients was " regular " until her death, which oc- 
curred in her sixty-second year. If the patient's mother and sis- 
ters ceased to menstruate as early as thirty or thirty-five, it might 
modify your diagnosis. Usually, if the suppression is from a 
morbific cause, it is preceded by a failure of the general health, 
and each month the patient complains of symptoms which pertain 
most decidedly to the return of the old habit. But, when the 
climacteric has been reached, and the arrest of the flow is charge- 
able to a physiological arrest of function, the ill health, if there is 
any, follows the change, and the monthly exacerbation does not 
recur. 

Treatment. — You have, doubtless, drawn the proper inference 

with respect to the treatment for this form of amenorrhea. Cure 

the original, idiopathic disease upon which this 

A cardinal rule. . . , . , 

suppression is secondary, and, in the great ma- 
jority of cases, if there be no organic obstacle, this particular func- 
tion will be reestablished. Or as Dr. William Hunter worded it 
in his Lectures, " With regard to the management of the menses, 
my opinion is, that you should pay no regard to them, but en- 
deavor to put her to rights in other respects. If you cure the 
other disorders, you cure the irregularity of the menses, which is 
the consequence and not the cause of her complaints." 



ON THE DISEASES OF WOMEN. 385 

If the suppression is due to chlorosis, ovaritis, metritis, incipi- 
ent tuberculosis, pneumonia, pleurisy, gastritis, hepatitis, rheuma- 
tism, or any other abnormal condition or diseased process, the in- 
dication presented is to cure the primary affection, after which we 
may reasonably expect the secondary one to disappear. Fortu- 
nately we find that remedies are possessed of corresponding rela- 
tions to the various functions. For not only are the bodily organs 
linked in sympathy and susceptibility, but these sympathies and 
susceptibilities have their counterpart in the curative range of our 
remedies. The different sections of a correct and complete 
pathogenetic record are as intimately related as the several cantos 
of a grand old poem. 

If, therefore, you shall find that the remedy which is manifestly 
indicated for the cure of the complaint upon which the amenor- 
rhea is secondary, is also applicable in case of 

Emmenagogues. . tit -r-» 

menstrual suppression, so much the better. But, 
as between prescribing pulsatilla, or senecin, or any of our medi- 
cines as emmenagogues merely, or iron, secale cornutum, and aloes 
in ponderous doses with the same end in view, there is really no 
difference. Both methods are unphysiological and harmful. 

Abundant experience has satisfied me that the calcarea carbon- 
ica is, perhaps, the most prominent and useful remedy for the re- 
lief of those menstrual irregularities which are 
ticns!" pec ° mp lca " incident to pectoral disease. It seems especially 
appropriate to complicated cases of pulmonary 
and uterine disorder in weakly, ill-conditioned females of a scrof- 
ulous diathesis, with amenorrhea, an impoverished state of the 
blood, and a depraved condition of the nutritive system. 

Pulsatilla is indicated in women with light hair and blue eyes, 
who are weakly, pale, and delicate, of mild and amiable disposi- 
tion, and who are tearful and . prone to melan- 

For suppression alternat- -i -i T , • , . ,, . , 

ing with ophthalmia. cnoly. It is sometimes an excellent remedy in 

case of menstrual suppression complicated with 
ophthalmia. My attention was called to this fact some years ago 
by my excellent friend the late Dr. Lyman Kendall, of this city, 
who related the following 

Case. — Mrs. , aged 32, had suffered frequent attacks of 

amenorrhea, which persisted for from three to six months at a 
time. The suppression came without any apparent cause, and 
25 



386 LECTURES, CLINICAL AND DIDACTIC, 

the return of the flow did not seem to be influenced in the least 
by any medicine which she could take. Her general health was 
good. She had never been sick in bed, and suffered no ill conse- 
quences of the amenorrhcea, excepting an intractable and trouble- 
some inflammation of the eyes. Upon inquiry it was found that 
this inflammation came and went regularly, alternating with the 
amenorrhcea. When the catamenia were prompt and regular the 
conjunctivitis disappeared altogether ; but when they were sup- 
pressed, the eyes became inflamed again. There was redness and 
swelling of the lids, lachrymation in the open air, and irritation 
and pressure as from sand in the eye. Pulsatilla 6 cured both 
these affections promptly and permanently. 

I may give you an idea of the special indi- 

t rom various causes. ° ° d x 

cations for other remedies as follows : 

a. In suppression from mental causes — Staphisagria or colo- 
cynth, if from indignation and chagrin ; opium or coffea, sudden 
and excessive joy ; chamomilla, from anger ; opium, aconite or 
lycopodium, from fright. 

b. From check of perspiration — Chamomilla, cuprum. 

c. From changes in the weather, cold and damp — Dulcamara, 
rhododendron, nux mosch., pulsatilla. 

d. Suppression with prominent mental symptoms — Stramo- 
nium, great loquacity, is tearful and supplicative at the month ; 
natrum mur., for anxiety, solicitude, melancholy; ignatia, with 
sighing and hysterical sobbing ; hposcyamus, singing delirium, 
spasmodic jerkings and twitchings, and excessive laughter ; bel- 
ladonna, with intolerance of light and noise, which make her head 
ache severely, and almost craze her ; magnesia mur., for great 
excitement habitually, or accidentally, whenever the menses are 
due ; aurum met., arrest of menses with inclination to commit 
suicide ; macrotin, in rheumatic subjects. 

e. If attended with soreness of the throat — Belladonna, magne- 
sia mur., mercurius jodatus. 

/. With ophthalmia — Pulsatilla, euphrasia. 

g. With swelling of the breasts — Conium, zincum. 

h. With hemorrhage — Phosphorus, if from the lungs, the 
stomach, the bowels, or the urethra ; bryonia, for incidental or 
vicarious epistaxis. 

t. With indigestion — Kali carb., for sour eructations, with fugi- 



ON THE DISEASES OF WOMEN. 387 

tive, shooting abdominal pains ; mix vomica, arsenicnm alb., po- 
dophyllin, lachesis, mix moschata. 

j . With cardiac distress — Lachesis, apis mellifica, bryonia, 
aconite, lilium tig., macro tin. 

k. With abdominal tympanites — Belladonna, phosphoric acid, 
chamomilla. 

I. With dropsy — Apis mel., for incidental anasarca, swelling 
of the feet, puffiness of the cellular tissue; helleborus, for ab- 
dominal dropsy, with scanty flow of dark-colored urine ; arseni- 
cum. Dr. G. W. Barnes* reports " invariable success with apo- 
cynum can. in quite a number of cases of amenorrhcea in young 
girls, attended with bloating of the abdomen and extremities." 
He also had "good success with it at least in one case of this dis- 
ease in which the latter symptoms were not marked." 

m. With chorea, hysteria,^ etc. — Belladonna, gelseminum, Pul- 
satilla, macrotin, hyoscyamus, coffea, ferrum cit. et strychnia (in 
the 3d dec. trit.), cocculus, cuprum, causticum. 

I am aware that these hints are more suggestive than satisfac- 
tory. Their chief value consists in the possibility that they may 
help you to decide between two or more remedies which, other- 
wise, might seem to be equally appropriate, and in this manner 
serve a good purpose. As a rule, however, in 

A practical hint. & r r 

functional amenorrhcea, which is consequent 
upon different morbid states, whether they are acute or chronic, 
the symptoms proper to those conditions, and which would be 
your guide if there were no suppression, will indicate the remedy 
or remedies that are especially indicated. 

But if the suppression is idiopathic (which is comparatively 
rare), you will naturally seek to stimulate the functional activity 

of the ovaries, and of the uterine mucous mem- 
ber idiopathic suppres- ^^ rp^ may be accomplished without the 

use of harsh emmenagogues. Pulsatilla, sepia, 
calcarea carb., podophyllin, apis mel., natrum mur., ferrum, china, 
phosphorus, sabina, sulphur, platina, or, among the newer reme- 
dies, senecin, collinsonia can., and the asclepias in., are sometimes 
gWen with excellent result. Dr. C. D. Williams reports some 
remarkable cures with xanthoxylum.J 

* Hale's New Remedies, 1867, p. 83. f See page 56. % United States Med. 

and Surg. Journal, October, 1871, p. 35. 



388 LECTURES, CLERICAL AND DIDACTIC, 

The general treatment is sometimes even more important than 
the special. In the temporary suppression which frequently fol- 
lows marriage, a single coitus, or change of cli- 

General treatment. _ . . „ _ 

mate and occupation, it you are careful not to 
overdo in the matter of dosing, and will take pains to correct the 
patient's habits, the function will regulate itself. In every case, 
she should take the fresh air daily. Walking, or riding in the 
sunshine, cheerful society, keeping the feet warm and dry, diver- 
sion, and a proper and nourishing diet, are useful auxiliaries to- 
wards a cure. They will help to restore the vital conditions 
which are inherent to this function, and indispensable for its 
proper performance. And they will also fortify the system 
against a degree of asthenia which is quite incompatible with 
ovulation. 

In those who are predisposed to an arrest of the menses great 

care should be taken at the month lest a slight indiscretion or 

exposure induce it. With some women all that 

At the month. . 

is necessary is lor them to lie down and keep 
tolerably quiet and passive for one or two days. In others the 
flow will need prompting by appropriate internal remedies given 
in anticipation thereof ; by the foot or sitz-bath ; by an enema of 
tepid water thrown into the rectum ; or by the introduction of the 
sponge-tent through the uterine cervix some hours, or perhaps 
the night before the flow is due. In some cases the passage of the 
uterine sound, or probe (which, if there is no uterine deviation, 
is not difficult at this period), may, by irritating the os uteri, pro- 
duce the same effect. The habit of taking spirits, as gin or 
whisky, and hot drinks, herb teas and the like, should not be 
encouraged, for the indirect effect of such palliatives is to unhinge 
the nervous system and to increase the difficulty. 

3. — RETENTION OF THE MENSES. 

In this form of menstrual irregularity there is a preternatural 
obstacle to the escape of the flow. Ovulation has been properly 
performed ; the secretion or exhalation of the menstrual blood 
from the uterine mucous membrane has been poured into the 
cavity of the womb, but there is no outlet for it. Either the 
canal of the uterine cervix, or the vagina, or both these portions 



ON THE DISEASES OF WOMEN. 389 

of the generative intestine, are closed, and there is no means of 
escape for the periodical discharge. 

Etiology. — Menstrual retention may be caused by atresia of the 
cervix uteri, resulting from post-partum inflammation or from 
cauterization ; spasmodic closure of the os in- 
ternum ; flexures and obliquities of the womb ; 
the presence of polypi, or of coagula, which serve to obstruct the 
passage ; atresia of the vagina ; or closure of the same by an im- 
perfect hymen. In exceptional cases it may be due to a species 
of uterine inertia. Here the flow exudes passively, but the 
condition of the patient's general health is so low, and the uterine 
fibre is so irresponsive to ordinary stimuli, that the peristaltic 
action of the womb is not aroused as it should be. The force that 
is designed to unlock the internal os and to expel the menstrual 
product is not called into exercise. The secretion is lodged, and 
there is no " show." 

Symptoms. — In this class of cases, the menstrual molimen is 
more or less pronounced. The symptoms are those which accom- 
pany normal menstruation, alwavs excepting 

The form without the flow. 1 . J . p -, -. -n • 

the sanguineous now irom the vulva, rams 
in the back and loins, around the pelvis, and down the thighs and 
limbs, bearing down and fullness within the pelvis, forcing pains, 
which are aggravated by standing or walking, headache, malaise, 
chills, nervous tension and perturbation, and sometimes dyspnoea, 
and diarrhoea or dysentery, recurring with some degree of regu- 
larity, may lead the patient to suppose the discharge is coming 
on. After a longer or shorter interval, however, these symptoms 
subside, and the effort to establish the flow has proved abortive. 
This state of things may continue for months, and even for years, 
to the manifest detriment of the general health. 

Diagnosis. — Proper retention of this flow can only occur in 
those who have menstruated before. For this reason, it could not 
be readily confounded with, or mistaken for, Delayed Menstrua- 
tion. The repeated efforts to expel the secretion, at each return 
of the monthly cycle, the kind and degree of suffering experi- 
enced, and the special clinical history of the case, would help you 
to differentiate between this form of menstrual derangement and 
a case of suppression, and also to diagnosticate it from " change 
of life," and from pregnancy. 



390 LECTURES, CLINICAL AND DIDACTIC, 

Prognosis. — The prognosis will vary with the cause of the dis- 
order, the age of the patient, and the condition of the general 
health. Other things equal, a recent case is more promising than 
a chronic one. If the blood has become deteriorated in quality, 
either from depraved nutrition or from the resorption of post- 
organic matters confined in the cavity ef the uterus, more serious 
consequences are to be apprehended. Or if, in consequence of 
the clamming up of the discharge, the ovaries have become seri- 
ously diseased, we would not promise a prompt and radical cure 
to follow the restoration of the menses. For in exceptional cases 
the removal of the obstacle to the menstrual discharge, whatever 
it may have been, fails to re-establish this very important function. 

Treatment. — The prime indication is to remove the cause of the 

retention. Atresia of the cervix can usually be overcome by the 

careful and persistent employment of the uterine 

Surgical means. .. __^ . , a -i i ti 

sound, or probe, rnestly s or Atlee s dilators, 
Simpson's ebony bougies, and the sponge tent. In rare cases the 
hysterotome may be requisite. I could cite many cases in which 
these means have cured retention of the menses due to atresia of 
the neck of the womb, occurring as a consequence of lying-in, 
and of excessive cauterization. 

When the trouble depends upon spasm of the internal os-uteri, 
the same dilatation may be necessary, but it should be conjoined 

with such internal and hygienic treatment as is 

Dilatation, etc. 1 

suited to overcome the tendency to local and 
general spasms. Here you will need to counteract the hysterical 
bias of the patient, and to place her under conditions which favor 
recovery. The topical and general use of electricity promises to 
be of great value in this particular class of cases. 

If the uterus is bent, or twisted upon itself, proper means must 
be taken to correct and cure the deviation. The most frequent 

of these displacements is retro-flexion, the womb 

Reposition of the uterus. . 

being curved like a retort, and the canal ot the 
cervix oblitated at the point at which the body of the organ is 
bent upon its neck. These cases are very tedious, but if you are 
really skillful, you will succeed in curing a large proportion of 
them. 

Polypi and coagula are to be removed by excision, and by 
dilatation of the canal of the cervix. Atresia of the vagina will 



ON THE DISEASES OF WOMEN. 391 

require a caieful dissection of its adherent mucous surfaces, after 
which the freshened edges must be separated 
andTflhe hymeT™^ either by an oiled tampon or Sims' dilators, until 
they are healed. If the hymen is imperforate, 
it must be divided in order to discharge the contained fluid. The 
old plan was to make a crucial incision into this septum in such a 
, case ; but, serious results having followed the too rapid evacuation 
of the fluid, modern authorities advise that the cut shall be valve- 
shaped instead. 

If the retention is referable to uterine atony, the general health 
must be built up and fortified, and local excitation and stimula- 
lation of the womb secured by electricity, bathing, frictions along 
the spine, and the use of remedies suited to the especial and inci- 
dental symptoms, whatever they may be. 



392 LECTURES, CLINICAL AND DIDACTIC, 



LECTURE XXIV. 



OBSTRUCTIVE DYSMENORRHEA. 



Gentlemen : 

One of my most intelligent and amiable patients has written 
the following history of her case, which, for the sake of the 
benefit that may accrue to others, she has consented that I may 
read to you : 

Case. — I hardly know if I were a healthy child, but I was active, 
impulsive and sensitive. At eleven years of age the menses ap- 
peared, the result, perhaps, of the grief and excitement caused by 
my mother's death. For about one year they returned regularly, 
with little pain, and then ceased, owing, I think, to wetting my 
feet, and improper exercise. The result was a cough, dyspepsia, 
and other bad symptoms. My father employed a physician for 
me, who, after several months of medical treatment, brought on 
the menses again, but with much pain. 

At seventeen years of age I was married, after which I resided 
four years in Boston. During these years, in which I experienced 
great mental suffering also, I suffered each month, resorting to 
such remedies as were prescribed in a domestic way by my friends, 
such, for example, as gin, injections of laudanum, chloroform, etc. 
About this time I was seized with "vomiting attacks," in which 
I would vomit a table-spoonful or more of clear green bile every 
ten or fifteen minutes for twelve hours, but never for a less time. 
As the vomiting, sometimes with purging, continued, the pain 
would lessen and finally disappear. The nausea and retching 
would leave suddenly and without apparent cause, for no medi- 
cine could be kept upon the stomach long enough to produce any 
effect. These attacks returned at intervals of three, five and eight 
months. I was treated for them by physicians in Elmira, N. Y., 
Boston, St. Louis and Chicago, and no one was able to relieve me, 
or to decide upon the cause of these paroxysms. 

During the latter half of this period of ten years, my general 
health was much impaired, and I suffered greatly from gastric irrita- 
bility and distress. From this irritation I have never found per- 
manent relief. 



ON THE DISEASES OF WOMEN. 393 

After four years' residence in Boston I came to Illinois, seeking 
no particular medical aid for some years. At length I was in- 
duced to try a water-cure in New York, where I had the first 
vaginal examination. As a result, I was said to be suffering from 
" an irritation of the uterus and vagina, and nothing more." I 
remained three months under treatment, but still continued to 
suffer during menstruation. 

A few years later I was placed under the care of a noted speci- 
alist in this city, who told me there was an " enlargement and 
retroversion" of my womb. He applied the caustic treatment for 
six months, and, although he declared that I "was cured," still I 
suffered as before at each menstrual period. 

One year after this I went to another Hygienic Institution in 
New York. Here I was told that the " uterus was enlarged, in- 
durated, retroverted, and fastened down, and had entirely changed 
its structure, and that the change must have been going on for 
many years." After having been pronounced " cured" only one 
year before, this was rather discouraging news. I remained at 
this institution four months, whence I was discharged, not as 
cured, but better. Still I suffered with menstruation. 

In the winter of 1870, severe pain preceded the flow for several 
hours, and in addition to symptoms threatening a return of all my 
former difficulties, my bladder was much affected. At this time, 
and after a careful examination of my case, Dr. Ludlam decided 
the seat of my difficulty to be " in the neck of the uterus," which 
he found was " almost entirely closed." Under his treatment I 
experienced almost immediate relief, my general health improved, 
the bladder troubla disappeared, the gastric disorder became less 
annoying, and I suffered little or no pain during menstruation. 
Six months have now elapsed since I have finished his treatment, 
and the cure seems permanent. 

Perhaps I should add that my pain was mostly in the abdomen, 
and of the nature of colic. Warm applications often produced 
fainting fits, and always had a tendency of that kind. Looseness 
of the bowels frequently accompanied the pains. I could only 
eat a very small amount of the simplest food. Eating always 
increased the pain. Finally, after nearly thirty years of painful 
menstruation, I have at last found relief! 

Obstructive Dysmenorrhcea is a variety of painful menstruation, 

which depends upon a partial or complete closure or obstruction 

of the canal of the uterine cervix, whereb}^ the 

Definition of. • r» ' ■ '-i-i ' • i 

menstrual now can only escape, if at all, with 
great suffering and more or less irregularity. Although it is by no 
means a rare affection, the history of this case proves that it may 



394 LECTURES, CLINICAL AND DIDACTIC, 

exist for months or years without being recognized and properly 
treated. 

The causes of this disease are various. Sometimes it depends 
upon the original conformation of the uterus and uterine neck, in 
which case, from the very first the " periods," are 
always characterized by unusual delay and suf- 
fering. More frequently, however, it is acquired at a later stage 
of menstrual life. It may result from a flexure of the womb, in 
which that organ is bent upon itself like a retort. Opposite the 
lesser curve, in this case, the cavity of the cervix is obliterated. 
Versions, prolapsus, and other deviations 

From uterine deviations. . . . _ 

m the position ot the uterus are less 
likely to cause this form of dysmenorrhoea than flexions. And 
retro-flexion is more frequent in every form of painful menstrua- 
tion than ante-flexion. 

In certain cases the cervico-uterine orifice and canal are 
mechanically obstructed by the presence of a foreign body, such 

as a polypus, a sub-mucous fibroid, or an old 

From intra-uterine growths. .. . 

coagulum, and, notwithstanding the most vio- 
lent efforts to expel the flow, it is partially or wholly retained 
within the womb. For this reason retention of the menses is 
often described by writers under the head of dysmenorrhoea, and 
vice versa. 

But a more frequent cause of obstructive dysmenorrhoea is a 
form of endo-cervicitis, in which the epithelial lining of the canal 

is exfoliated and lost, and, as a consequence, 

From cervical atresia. _ .. 

adhesions are formed between the opposite 
sides of the canal. These adhesions, whether traumatic, post- 
partum, or the result of a popular form of malpractice, that is of 
cauterization, cause an atresia which obstructs and practically 
closes the passage. 

As a rule, those women who have borne children, whether 
prematurely or at term, are supposed to be exempt from dysmen- 
orrhoea. But this form of the disease is by no means a rare 
sequel to the abrasions and injuries consequent upon labor, as well 
as to the local inflammations which may occur about aud within 
the cervix and the vagina during the puerperal state. 

The harsh and indiscriminate employment of escharotics for 
the cure of uterine ulceration (against which I have so frequently 



ON THE DISEASES OF WOMEN. 395 

cautioned you), is very mischievous in this respect. The actual 
cautery, or its potential substitute, the potassa 

From cauterization. n _ .. . , .. . 

cum calce, destroys the cervical epithelium, 
and there is nothing left to prevent the consequent adhesive in- 
flammation from sealing up the outlet. Without their epithelium 
these surfaces grow together, just as your fingers would if the epi- 
dermis that separates and protects them were removed by a burn, 
and the surgeon who dressed it did not know enough to keep them 
apart until a new cuticle had formed. From considerable ex- 
perience in this class of cases, I am persuaded that contraction, cica- 
trization, and even atresia of the cervix are frequent sequelae of the 
milder, as well as of the more severe and reckless cauterization 
to which so many of our patients have been subjected before they 
come into our hands. The case just cited affords a good illustra- 
tion of this fact. Mrs. — had already suffered from dysmenorrhea 
for several years. The symptoms were sufficiently marked to 
suggest their own solution and significance, even to a first-course 
student. But, as if to render her menstruation not only difficult 
but impossible, she, too, must be cauterized ! 

The symptoms of this disease are by no means limited to the 
site of the obstruction. Within the pelvis, and in the back and 
limbs, they are similar to those which ordinarily 
attend upon the menstrual effort. But in this 
case they are greatly exaggerated. When the patient is one 
who has never been pregnant, the uterine cavity is so small that 
the menstrual exhalation from its lining membrane soon fills it, 
and a feeling of distention and of extreme discomfort is induced. 
Aching and throbbing of the uterus, with uterine tenesmus are 
almost always present. In those who have borne children, and 
who have this form of dysmenorrhoea subsequently, the womb, 
if not really more capacious, is yet more tolerant of the retained 
fluid. These women therefore do not commonly suffer so severely 
as those who belong to the former class. 

In both classes, however, the presence and pressure of the 
blood, which has no adequate outlet, excites "the peristaltic con- 
tractions of the uterus with a view to over- 

Uterine tenesmus. . in 

come the obstruction and to lorce the now. 
The case then partakes of the nature of labor. The contractions 
of the uterus are much less powerful, because the fully-developed 



396 LECTURES, CLERICAL AND DIDACTIC, 

fibres of its muscular coat are lacking. But it often happens that 
they are more painful than in real labor. The antagonism be- 
tween the body and fundus and the circular fibres about the inter- 
nal os uteri is very apt not only to cause intra-pelvic suffering and 
agony, but to develop a train of reflex symptoms such as are met 
with in abortion and in labor at term. 

Of the functions which are thus indirectly implicated and de- 
ranged, that of digestion suffers most frequently. Obstinate and 
painful vomiting is almost always present with 
every return of the menstrual cycle, whether 
it be prolonged and complete or not. It depends upon a stricture 
of the os internum, and comes on in the same manner that it does 
in rigidity of the os uteri during labor, or at the moment that the 
presenting part passes through the ring that is made of the enor- 
mously dilated cervix. If there is ever so small a vent, and a 
portion only of the catamenial secretion escapes, the pain and 
emesis may subside. But, unless the flow comes on without any 
considerable delay, and pretty freely, the vomiting is likely to 
persist. And, what is a curious clinical fact, one that I am una- 
ble to explain, but which I have often observed, is that this vom- 
iting is almost certain to continue for about twelve hours. Our 
patient says that she vomited " every ten or fifteen minutes for 
twelve hours, but never for a less time." 

Some cases of obstructive dysmenorrhea a are met with in which 

the menstrual arrest and derangement have given rise to very 

complicated disorders of digestion, which many 

Indigestion. , . . . , . 

physicians are incompetent to explain and to 
cure. The gastro-intestinal functions are involved just as they 
often are in the early months of pregnancy. Either through 
nervous or vascular connection between the uterus and the stom- 
ach, some portion of the small or large intestine, or the liver, or 
all these organs, the result is the various forms of indigestion, in- 
anition, constipation and bilious disease that so frequently arise 
from painful and irregular menstruation. 

In this, as in other varieties of clysmenorrhoea, it would be im- 
possible for the bladder and the rectum not to 
pikadon! and rectal com " sympathize with the uterus in its prolonged 
effort to empty itself of its contents. Conse- 
quently there is, sooner or later, in almost all of these cases, more 



ON THE DISEASES OF WOMEN. 397 

or less of vesical and rectal tenesmus. This incidental suffering 

corresponds with that proper to the first stage of labor. 

Coincidently with the tenesmus of the pelvic organs there is 

often, and indeed usually, a train of nervous symptoms which are 

more or less pronounced and alarming. Head- 
Nervous disorder. . .... 

ache, restlessness, insomnia, jactitation, spasms, 
and even convulsions are not infrequent, all of which, however, 
are relieved as soon as the flow begins, exactly as in labor when 
the rigid os uteri has yielded and the presenting part has passed 
the point of obstruction. A very painful and distressing form 
of spasm to which some of these patients are subject is one in 
which the muscles of the back part of the head, of the neck and 
of the superior portion of the spine are affected, resulting in 
opisthotonos. Painful, cramping, clonic spasms of the flexors of 
the fingers and toes often occur. Some women are liable to a 
temporary blindness at these times, and you will observe the pupil 
to be sometimes very much dilated and again contracted. In 
those who are decidedly hysterical, there may be, during the par- 
oxysm, an evident disparity in the size of the pupils. 

In true obstructive dysmenorrhea it seldom happens that the 

painful and persistent effort to restore the impeded flow finally 

causes it to become profuse. In this respect it 

Menorrhagia infrequent. -,. nn P ,-, ,. tl -, . -, 

diners irom the congestive, the spasmodic, and 
the membranous varieties, which are all of them likely to be either 
accompanied or followed by menorrhagia. The amount of the dis- 
charge is not proportioned to the severity of the pain. The flow 
is scanty and intermittent, and, as in the case which I have 
related, the inter-menstrual period is generally lengthened and 
irregular. 

If the obstruction is congenital, or has come on from any cause 
before marriage, these patients are sterile ; for the same mechan- 
ical obstacle which interfered with the men- 
steriiityfrom obstructive strua x ex ^ w [\\ prevent the ingress of the 

dysmenorrhcea. J- o 

semen into the uterine cavity, and proper fecun- 
dation will be impossible. If the closure of the cervico-uterine 
outlet takes place in consequence of cauterization, or of post- 
partum inflammation in one who has borne a child or children, she 
also may afterwards become barren from the same cause. 



398 LECTURES, CLINICAL AND DIDACTIC, 

If the dysmenorrhcea depends upon congenital mal-formation 
of the cervix uteri this condition can be readily 

Diagnosis. . 

recognized by the proper employment of a Sims 
speculum and the uterine sound, conjoined with the "touch." 

If it had its origin in puerperal inflammation ; if it has followed 
the extension of simple or specific vaginitis into the canal of the 

cervix ; if it depends upon some uterine ob- 

Physical exploration. *? n • n 

liqmty, or the presence of a foreign growth ; or 
if it is the sequel of cauterization, the previous history and treat- 
ment of the case will facilitate the diagnosis. The simple fact 

that at the first attempt you fail to pass the 

Passing the sound. . . 

sound into the uterine cavity should not lead 
you to decide the case to be* one of obstructive dysmenorrhcea ; 
for in a healthy state of the uterine mucous membrane, and in 
the interval of menstruation, the internal os is in many cases so 
tightly closed that it requires considerable skill and experience to 
pass this instrument at all. But if the canal of the cervix is not 
absolutely impervious, a little patience and tact will enable you 
to succeed. You may sometimes insinuate a small Sims' probe, 
when a large sound, more especially a stiff one, could not be intro- 
duced without undue force and unnecessary suffering. I need 
hardly remind you that you will gain an entrance into the uterine 
cavity in this manner much more easily u at the month" than at 
any other time. 

You should remember that in this form of dysmenorrhcea there 
is not necessarily a complete and entire retention of the menses. 
The distinguishing characteristic of the disease 
sig'nmes^' and what h is tnat there is a mechanical impediment to the 
monthly flow, which may or may not amount to 
a positive obstruction and arrest thereof. The failure of the prac- 
titioner to get a correct idea of this fact explains the proneness to 
blunders in the diagnosis and treatment of this affection ; for ob- 
structive dysmenorrhcea bears as little resemblance to endo-cervi- 
citis and to uterine ulceration as it does to perimetritis or to heema- 
tocele, and to confound them is both inexcusable and mischievous. 

The prognosis will vary with the cause of the disease, and also 
with the consequences of the menstrual irregu- 

The prognosis. . . 

larity. If the original organic defect, whenever 
it exists, can be remedied or compensated by surgical means, 



ON THE DISEASES OF WOMEN. 399 

recovery will follow. If the acquired or accidental obstruction, 
whatever it is, can be removed, the result may be favorable. 
Something, however, will depend upon the state of health, which 
is secondary, and which has been induced, directly or indirectly, 
by the persistent derangement of the menstrual function. If the 
dysmenorrhcea has existed for years, the patient may be so ill with 
symptomatic endometritis, gastritis, gastro-enteritis, ovaritis, cys- 
titis, chronic hepatic and digestive derangements, tuberculosis, 
diseases of the nervous system, or a depraved condition of the 
blood, as to prevent her complete recovery. And this, although 
the ease and regularity of the flow have both finally been estab- 
lished. Therefore, you should be careful how you promise to 
perform a radical cure of this painful affection. 

Treatment. — One of the most successful and satisfactory 

achievements of modern gynaecology consists in having supplied 

us with the means of cure for most cases of this 

Surgical treatment. 

disease. Jbrom the nature ol its causes, you 
will infer that the treatment of obstructive dysmenorrhcea must 
be chiefly of a surgical kind. Internal remedies are suited to the 
relief, and possibly the cure, of other varieties of painful menstru- 
ation, but they are of little or no permanent avail in this. The 
cause of the suffering is physical and mechanical, just as in a case 
of stone in the bladder, or of biliary calculus, and although, by 
the use of constitutional means, we may mitigate the pain and 
other incidental symptoms, yet the cure will depend upon the 
removal of the cause. 

If the seat of the stricture is at the os externum, a slight inci- 
sion may suffice to open the cervical canal. If, as most frequently 
happens, it is at the os internum, it will be most prudent to try 
the virtues of dilatation, and reserve the cutting as a dernier 
ressort. Dilatation is equally applicable to most cases of atresia 
of the cavity of the neck of the organ. 

When the passage is very narrow you will begin with a small 
copper sound, or probe, which may be passed every third or fourth 

day until the canal is somewhat enlarged. 

This may be followed by the ordinary sound, 
small bougies, laminaria, or slippery elm tents, the use of Atlee's, 
Priestley's, or Nott's dilators, and finally by the sponge tent. And 
although (in order to take advantage of the natural tendency to 



400 LECTURES, CLINICAL AND DIDACTIC, 

expansion of the cervix), it is best to commence this treatment at 
the month, it must be continued during the inter-menstrual pe- 
riod alt^o. As a rule, twice each week is as often as these opera- 
tions can be borne, and sometimes this is too frequent. 

As in passing the female catheter, so you will need to exercise 

considerable tact in the introduction of these instruments, more 

especially until, by repeated trials, you have 

introduction of the neces-i earne ^ the course and curve of the canal in 

sary instruments. 

each particular case. For its direction is so 
modified by the position of the patient, the fullness or emptiness 
of the bladder, the rectum, and even of the uterus itself, as well 
as by obliquities of the womb, that any rules which I might 
indicate would be of little practical service, unless you should 
modify them to suit the case in hand. As a rule, the copper 
sound is preferable to the stiff one ordinarily employed. Sims' 
probe is too flexible, and might stick fast in. the rugae of the cer- 
vix, or at the point of coarctation. If the womb is retro-flexed, 
the patient must be placed in the semi-prone, and, if needs be, in 
the knee- elbow position, in order that the fundus and body of the 
organ may gravitate into their normal relations, and so that, in 
passing, the point of the sound may take the natural direction 
with reference to the axis of the superior strait. The most diffi- 
cult cases are those in which the cervical canal is tortuous and 
sinuous. You may or may not make use of the speculum to facili- 
tate the introduction of the sound, or of the tents. In all ordinary 
cases I prefer to pass them without, instead of through the specu- 
lum ; but perhaps you will do better with it. 

Much has been said of the frequent failure of dilatation of the 

cervical canal as a cure for this disease, and also of the injurious 

consequences that sometimes result from it. 

Failure of dilatation. ^ . . . 

My own opinion, which needs a word of ex- 
planation, and which is based upon experimental and not upon 
theoretical grounds, is that, if properly employed, dilatation is 
more successful and less harmful than is generally supposed. I 
am inclined to attribute its failure in the hands of some physicians 
to a lack of caution on their part in the choice and application of 
instruments ; and also to too great haste to cure their patients, 
regardless of consequences. 

That cervicitis, cellulitis, peritonitis, spasms, convulsions, and 



ON THE DISEASES OF WOMEN. 401 

even hysterical tetanus, have sometimes followed the use of the 
dilators and of the sponge-tents is doubtless 

Reported danger from. . .. . „ , 

true, but there is little question that, it the cor- 
rect and complete history of these cases were written, it would be 
found that either the tents were composed of improper material, 
were too large, or were pushed through the cervix uteri too forci- 
bly, or that they were allowed to remain for too long a time before 
being removed. One of my patients suffered so severely that she 
could not tolerate a small ebony dilator, which was passed with- 
out difficulty, for more than ten minutes at a time. If I had not 
taken the precaution to remain with her and to observe the effect, 
but had left her with instructions that the instrument must be 
kept in place for some hours, she might have been dangerously ill 
from this cause alone. 

It may seem incredible, to the more advanced members of the 
class especially, that any intelligent physician should be so care- 
less as to introduce a slippery-elm or a sea- 
tangle tent at his office, and afterwards permit 
his patient to travel by stage or by rail for some miles to her resi- 
dence, before it was removed ! But this is not an infrequent 
occurrence, more particularly with those who practice most 
largely among the lower classes in such a city as this. The inju- 
rious effects of such a custom should be charged to the abuse and 
not to the proper use of the tent. 

Providing there is no acute inflammation of the endometrium, 
or of the mucous lining of the cervix uteri, no ulceration, and no 
extensive or deep-seated cicatrices to be broken 
di£mt C ion Ions concernIns up, I think that the whole or any portion of the 
neck of the womb may be as safely, although 
not so rapidly dilated, as the female urethra. In exceptional 
cases, where the obstruction has been relieved by dilatation, it 
returns after six or eb'ht months. 

Mischief sometimes results from a lack of care in the choice of 

the material of which the tent is made. The slippery-elm tents 

are useful and available, and answer a very 

Of the various tents. 

good purpose when they are smooth and small 

enough to permit them to take the shape of the canal through 

which they are to pass. But when a larger tent is requisite, they 

are too stiff and straight to suit many cases. A large sea-tangle 

26 



402 LECTURES, CLINICAL AND DIDACTIC, 

tent expands so slowly as to be practically useless, and to try to 
introduce several small ones at once, or, rather into the same cer- 
vix, that they may expand simultaneously, is a blundering and 
unsatisfactory operation. The hard rubber bougies are of various 
sizes, and can be bent into the desired form by heating them over 
a lamp, which items are much in their favor ; but they are too 
blunt for use in the early stages of treatment, when the passage 
is very narrow. If the sponge tent is an old one, it is apt to be 
hard and unsuitable. Moreover, when kept in contact with the 
cervico-uterine fluids, such a bit of sponge will more readily de- 
compose. Now that our sponge tents are carbolized, however, it 
is quite probable that some of the evil consequences attributed to 
the use of this instrument will be omitted in future. 

The rashness and injudicious haste with which dilatation has 

sometimes been practiced, have excited a prejudice against it in 

the minds of many. There are physicians who 

Precautions in practicing undertake to dilate the contracted cervix in 

dilatation. 

obstructive dysmenorrhcea with the same dis- 
patch with which a surgeon would amputate a limb, or excise the 
tonsils. The whole operation must be performed at once, and the 
unfortunate results that may follow are almost invariably attrib- 
uted to the instruments used, instead of to the lack of discrimina- 
tion and judgment on the part of the operator. The proper plan 
is to " feel one's way," as the phrase is, and to take plenty of time 
in order to overcome the obstruction without any serious shock 
to the patient's system, or any risk of the diseases which I have 
named as contingent upon this operation. If you cannot succeed 
in one month, it is better to take two or three, or six, if need be* 
and to make gradual progress towards a cure, than to be precipi- 
tate and finally to bring yourselves to condemn this expedient al- 
together. The cautious and persistent dilatation of the cervix 
was the only means employed in the case cited at the opening of 
this lecture. I have resorted to it in many other instances with 
equally good results. 

When, however, you have made a faithful trial of dilatation, 

and it has failed to bring the hoped-for results ; 

^incision of the cervix 01% jf a £ ter nav i ng a ff rded temporary relief, 

there is a serious relapse, and you are satisfied 
that a radical cure is not possible by this means, incision of the 



ON THE DISEASES OF WOMEN. 403 

cervix is a final resource. I do not say that you should never 
have recourse to this latter expedient before having tried the 
method by dilatation, but only that I think it more prudent and 
preferable to hold this operation in reserve, both because it is 
beset with more real danger, and also because, if it will answer, 
the simpler means is the safer of the two. There are cases, un- 
doubtedly, in which the incision or slitting of the cervix is indis- 
pensable. 

Concerning the method of performing this operation, I cannot 
do better than to call your attention to the remarks of my friend 
Dr. T. G. Comstock, of St. Louis, upon this subject.* 

" The patient is placed before a good light, in the left semi- 
prone position, a little inclined trpon the chest, with the knees 
well drawn up against the abdomen, and the hips on the edge of 
the mattress, when the speculum is introduced (we usually em- 
ploy Cuzco's), and the uterus exposed between its blades. By 
means of a wire tenaculum, the uterus is seized and drawn down 
a little, and fixed by slipping one of the loops of the tenaculum 
over the brim of the speculum ; then with a pair of Sims' curved 
or angulated scissors (one blade of which is carefully introduced 
within the os, just far enough to cut through to the junction of the 
cervix with the vagina, the handles of the scissors being closed), 
the section of the cervix is made first on the right side, and 
then in the same manner on the left side. Now the whole opera- 
tion is half completed. The scissors being withdrawn, the metro- 
tome is to be introduced. The instrument we employ is Dr. 
White's, and it looks not unlike the ordinary uterine sound, but 
is armed with two concealed cutting blades, which are regulated 
by a screw in the handle. This instrument is passed within the 
uterine canal, an inch and one quarter or more, above the incision 
already made ; then the cutting blades are carefully expanded 
and the instrument is to be withdrawn, cutting its way out, so 
that the os internum is incised on each side. It has been advised 
to introduce the instrument again, and make sections of the os 
internum, exactly at right angles with the preceding, but the 
utility of this last recommendation is doubtful. After the incision, 
there will be a little haemorrhage (occasionally a very severe one, 
although, fortunately, in over thirty operations we have never 

*U. S. Medical and Surgical Journal, vol. vii, page 134. 



10-1 LECTUBES, CLINICAL AND DIDACTIC, 

seen it), which may be stopped by washing the blood away with 
ice-water, or by applying persulphate of iron solution, diluted in 
three parts of glycerine, then, by means of a pyramidal-shaped 
piece of cotton, saturated with the preparation spoken of, the cut 
surfaces are to be well packed by introducing the same, and then 
below this is to be placed a second large piece of wetted-cotton, 
so as to maintain in situ the cotton between the cut surfaces of 
the uterine canal. The patient is then carefully placed on her 
back, and required to keep still, and take a plain diet. I usually 
leave the dressing quite undisturbed for about thirty-six hours, 
then the speculum is introduced, and the cotton all removed. 
The uterine sound is carefully introduced, and the cut surfaces 
touched with it, so as to prevent union, then cotton saturated 
with carbolic acid one drachm, in solution with one ounce of gly- 
cerine, is introduced, and pushed up as high as possible between 
the cut surfaces, and this is packed with a good supply of cotton 
saturated in pure glycerine. 

"In order to make the operation a success, the dressing should be 
changed every second day, for fourteen days, and the uterine 
sound occasionally carefully passed. Sometimes the canal will 
seem to contract in spite of the operation ; in such a case a sea- 
tangle tent may be introduced and maintained in place some 
tweh*e hours or possibly longer, by packing cotton in glycerine 
below it. 

i -This operation should always be undertaken just after the 
patient has menstruated, so that she may be well before the next 
menstrual period. It requires seventeen or eighteen days after 
the incision for the parts to entirely heal. The operation may be 
made with or without the inhalation of chloroform. We usually 
prefer to give the chloroform. " 

Instead of Cuzco's speculum, I use Sims' : and for the wire 

tenaculum, recommended by Dr. Comstock, I would substitute 

this little uterine tenaculum, which is Nott's. 

Qualifications. . . 

For making the incisions, I have always em- 
ployed Simpson's hysterotome, and this most frequently to the 
exclusion of the primary slitting with the scissors, which, in or- 
dinary cases, where there is no especial induration, hypertrophy, 
no uterine haemorrhage or intra-uterine fibroids, and no conical 
enlargement 01 tiie cervix, appears to me to be unnecessary. It 



ON THE DISEASES OF WOMEN. 405 

may be requisite to repeat the operation two, or even three 
times. 

Without great care in its performance, there is danger of sud- 
den and fatal haemorrhage, hsematocele, peritonitis, cellulitis, or 
endo-metritis. The risk of these accidents is 
in ratio with the extent and depth of the in- 
cisions which are made through the os internum, and also in the 
abdominal portion of the cervix uteri, at a point superior to the 
insertion of the vagina. Something will likewise depend upon the 
predisposition to surgical fever and inflammation which the 
patient may possess, as well as upon accidental circumstances that 
may favor or retard her recovery. After the operation she should 
be kept in bed for a number of days. Fatal 

Precautions. ..,.,, -. . r , , 

peritonitis has been known to occur irom a lack 
of care in this regard, as late as the tenth day after the incision. 
In every case the patient and her immediate friends should be 
made acquainted beforehand with the nature of the proposed 
operation, the dangers with which it is beset, and the possibility 
that it may need to be repeated before the cure can be considered 
complete. 

NEURALGIC DYSMENORRHEA. 

Case. — I was called September 16, 1860, to visit Mrs. , 

aged 21, of tall, slender habit, nervo-sanguine temperament, and 
a most amiable disposition. Found her suffering from intense 
neuralgic pains in the uterine, lumbar and ischiatic regions. Her 
period had passed as usual more than a fortnight before, and for 
ten days previous to my first visit, these paroxysms of neuralgia 
had taken on an intermittent type, recurring every afternoon. 

My patient had first menstruated at the age of thirteen. She 
has never had any retention of the flow, but has always suffered 
extremely. Has been married about six months, but has not been 
pregnant, nor has she experienced the least change in her men- 
strual symptoms since her marriage. In February last, while 
residing in Western New York, she had a severe attack of diph- 
theria. This was followed by rheumatism, or rheumatic neuralgia 
of the left arm. When the menses returned at the next month, 
there was a metastasis of this pain to the lumbar and uterine re- 
gions. From that time until the present the " period " has been 
characterized by the most intense suffering. Indeed there is no 
very decided remission of her suffering excepting for about one 
week in advance of the flow. For the day and night immediately 



406 LECTURES, CLINICAL AXD DIDACTIC, 

preceding the appearance of the catamenia her sufferings are al- 
most intolerable. She becomes exceedingly nervous, and restless, 
or wild with excitement, delirious, or has cramps and spasms of 
the most frightful kind. 

For the relief of the neuralgia, I prescribed, in turn, arsenicum, 
cocculus, coffea, hyoscyaraus, and, with the return of the scanty 
flow, apis mellifica, and caulophyllin. These remedies were re- 
peated at reasonable intervals, — each of the two latter palliating 
somewhat the severity of the symptoms at first, but subsequently 
proving of no effect. 

On the afternoon of the third day of the flow she had severe 
hysterical convulsions, which were controlled by moschus in the 
third decimal trituration. This remedy, however, only made her 
the more sensible of her sufferings. 

After treating her most assiduously through the next menstrual 
interim — during which time she experienced but partial relief 
from the neuralgia, — the recurrence of the catamenia, on the 
25th of October, was marked by precisely the same symptoms as 
before. It was impossible to discover that a single point had been 
gained by some six weeks' faithful trial. 

Convinced of the existence of a local cause for the mischief, I 
proposed an examination per vaginam. Passing my ringer care- 
fully towards the external os uteri. — the vaginal walls being al- 
most as closely contracted as in vaginismus, and the patient in 
intense pain, — I found the womb in situ, and the lower extremity 
of the cervix quite normal to the touch. On going a little higher, 
in order to ascertain the condition of the upper portion of the neck. 
my finger fell into a groove which extended all the way around the 
organ at the junction of the vaginal portion with the lower seg- 
ment of the womb. This very marked constriction led me to in- 
fer that there was a decided spasm of the circular fibres of the 
neck of the uterus, or in other words a stricture of the cervix, 
leaving it in much the same condition as if it had been ligated at 
that point. 

Simpson's sound was passed without difficulty as far as the os 
internum, but by no manipulation could I succeed in carcying it 
into the uterine cavity. A smaller probe, made expressly, was 
afterwards introduced, then the so and, and finally this little silver 
instrument, which resembles one of Simpson's intra-uterine pes- 
saries, was passed completely through the cervico-uterine canal. 

This instrument was carefully adjusted at nine in the evening, 
one day in advance of the expected flow. She was instructed to 
lie quietly upon the back as long as possible, in order that it 
might not be displaced, or drop away. It was retained until 
twelve o'clock— three hours — when it came away of itself. 
After this she enjoyed a tolerably good night's rest. The next 



ON THE DISEASES OF WOMEN. 407 

morning the flow came on, and more freely than usual, and with 
less of suffering than she had experienced for years before. Once 
only during this period the flow became scanty, when a few doses 
of apis mellificas brought it on again, but without any return of 
the neuralgia. 

Contrary to my expectations, the relief seemed permanent. 
During the next inter-menstrual period she appeared to be quite 
well ; rode out almost daily, attended evening parties, danced and 
sang (for she was a favorite singer), and was indeed the happiest 
woman in the city. The only subsequent trouble experienced was 
six months later, when she had a slight attack of uterine colic, 
which was promptly relieved by ignatias- 

There are several points of interest connected with this case, 
the practical relations of which -may interest you. Apart from 
its chronic nature, and the degree of suffering 
kaTexpES 060 ^ 1175 " iuvolved, the fact that she had been treated by 
several eminent physicians in different parts of 
the country with such a signal want of success, leads one to in- 
quire into the reasons for their failure. The more obvious of 
these reasons evidently was the lack of a correct diagnosis. The 
husband assured me that but one of the doctors had ever proposed 
an examination of this case per vaginam, and that one was not 
permitted to make it. For this reason, — because they did not 
pursue this investigation as they should have done, — the whole 
corps, embracing distinguished practitioners of both schools, failed 
to bring relief. . Indeed my immediate predecessor had told the 
patient's friends that nothing could be of more than temporary 
benefit, and accordingly prescribed the free use of the sulphate 
of morphia, which I found her in the habit of taking ad libitum, 
and in incredible quantities. 

Such an oversight is scarcely excusable upon any grounds what- 
ever. As physicians we should respect the delicacy of the sex, 
and the cautions enjoined and practiced by the profession against 
all unnecessary and unwarrantable officio usness in trivial cases, 
where a manual examination is uncalled for ; but to allow any 
squeamish scruples to be in the way of the patient's recovery, or 
to fancy that constitutional remedies given in the dark, are capa- 
ble of removing a mechanical difficulty of this kind, argues both 
a criminal and a crazy neglect of duty on the part of the doctor. 

It is worthy of remark that by proper means the diagnosis was 



408 LECTURES, CLINICAL AND DLDACTIC, 

not difficult, and that the relief afforded by the single introduce 

tion of this dilator was complete and perma- 

Entire relief through a nen t. I saw my patient three years later, and 

simple operative expedient. ./ a j 

she had had no return of the difficulty. In this 
operation there was no cutting of the contracted cervical fibres, 
for, as you perceive, this instrument has no edge with which to 
divide them. The mere passage of the smaller sound, and then 
of the larger one, did not accomplish the result, for their use in 
the first instance did not lessen the pain and suffering in the least. 
There were no evidences of existing or of previous inflammation; 
and if there had been, we can not suppose that so simple and 
transient a means could possibly dispose of them so instantane- 
ously almost, and so entirely. 

This case was evidently one of neuralgia, a pure neurosis, de- 
pendent upon permanent contraction of some of the circular 

fibres of the upper portion of the cervix uteri, 

unaccompanied either by inflammation or its 
consequences, but presenting its symptoms both during the 
monthly flow and also in the interval between the periods. 

In most cases of neuralgic dysmenorrhea, the pain and suffer- 
ing are limited to the monthly return. Any undue determination 

of blood to the uterus, or even a slight delay in 
Symptoms of neuralgic the appearance of the discharge, incidental irri- 

dysmenorrhcea. -L J- o 7 

tation or displacement of the organ, or ulcera- 
tion or inflammation thereof, may be the exciting cause of the 
attack. The pain may be limited to the pelvic or the ovarian 
regions, or it may assume the form of neuralgia located elsewhere, 
as in neuralgic headache, neuralgia of the face, the teeth, the 
eyes, the fingers, the toes, the mammse, the intercostal spaces, the 
stomach or bowels, or even of the heart. In such cases the suf- 
fering commonly subsides when the " period " has passed. But, 
exceptionally, as in the case of which I have spoken, where the 
local spasm or irritation of the cervix is perpetuated, the remote 
pain and suffering do not subside, but persist throughout the 
month. You should remember this fact, else the continuance of 
this form of secondary neuralgia may lead you to suppose that it 
has no possible connection with the uterus. 

In those who are predisposed to this form of dysmenorrhea, 
and who are generally of a neuralgic tendency, the slightest excit- 






ON THE DISEASES OF WOMEN. 409 

ing causes may induce it. One of my patients, a very observing 
and truthful person, who had had this disease 

Causes of dysmenorrhea. 

for many years, remarked that when she ate very 
lightly, on the advent of the menses, the suffering was very much 
lessened. Her habit was to diet herself strictly the day before 
the flow came on, and to eat sparingly of light food until it ap- 
peared freely. A hearty meal at the beginning of the period 
would increase the suffering in a ten-fold degree. 

All those habits of mind and body, which induce prostration 
and perturbation of the nervous system, are likely in those who 
are impressionable, to bring on this form of painful menstruation. 
The incidental suffering, as in neuralgia, is always periodic and 
paroxysmal. A predisposition to this peculiar kind of nervous 
derangement, which implicates menstruation and involves great 
suffering, runs in families, and, during the first few years of their 
menstrual and sometimes of their married life, every daughter 
will be the victim of these functional derangements. Not unfre- 
quently the most aggravated cases of neuralgic dysmenorrhcea 
occur in the experience of those women whose married life is an 
unhappy one, and who, either from a physical inaptitude for, 
loathing, or an excess of venery, suffer the evil consequences of 
forcible, frequent or incomplete intercourse. 

When the flow commences, the pain usually remits. And this 

is true however remote its location. But sometimes the relief is 

more direct and positive. Only yesterday a 

th?de a gr°ee of jw™ t0 lac ty tolcl me tnat sne aiwa y s feit Hght of heart 
and buoyant immediately the Aoav began, al- 
though but a few minutes before she had been in real agony, and 
was peevish, irritable, and extremely sensitive to any little slight 
or injury. The relief sometimes re-acts in such a way as to bring 
on a hysterical fit of crying or weeping, or of both these together ; 
or it may be followed by tranquil and refreshing sleep. In very 
rare cases it is followed by inordinate sexual desire, amounting to 
temporary nymphomania. 

You will sometimes, but not always, find the distinctive and 

characteristic indications for the remedy in the 

rem'Sie? 10115 f ° r internal kind., degree, location, and especial peculiarities 

of the pain, wherever it may be seated. These 

details are so varied, and so insusceptible of classification, that 



410 LECTUEES, CLINICAL AND DIDACTIC, 

you will be compelled to select from a list of remedies which 
are suited to the cure of every shade and form of neuralgia. 

Acting upon the hint that so slight a cause as the swallowing 

of a teaspoonful or two of cold water may cause a spasm of the 

uterine cervix, with scanty and painful flow. 

warm instead of cold my friend, Dr. M. F. Page, has sometimes given 

water. •> ° ° 

gelseminum z , fifteen drops in half a teacupful 
of warm water, one teaspoonful to be taken every five minutes 

until relieved, then less frequently with the 

happiest results. In this form of dysmenor- 
rhea, at or near the climacteric, he has great confidence in verat- 

rum viride *, five drops in the same quantitv of 

Veratrum viride. 

warm water, and the same dose repeated every 
ten or fifteen minutes. Yet, it often happens, that what will re- 
lieve one case will in another case seem to be without effect, even 
where the symptoms are very similar. 

There are some cases of this disease which can be cured most 
promptly and satisfactorily, and without any harmful conse- 
quences, bv the use of local means. Carefnl 

Dilatation. . " .-,.,., 

dilatation may suffice — as it did with my pa- 
tient — to paralyze and overcome the morbid spasm and hyperes- 
thesia of the uterine cervix, upon which the whole mischief really 
depends. In neuralgic and spasmodic dysmenorrhcea, I think it 
better to perform this operation with solid than with sponge tents. 
Indeed, in some cases of this kind, I have remarked a singular ag- 
gravation of the suffering from the use of the latter, especially 
when introduced in advance of the flow. 



ON THE DISEASES OF WOMEN. 411 



LECTURE XXV 



UTERINE SURGERY versus UTERINE THERAPEUTICS. 

Gentlemen : 

The line of demarcation between sanity and insanity, animal 
and vegetable life, and this world and the next, is not more indefi- 
nite than that which separates surgical from therapeutical indica- 
tions in the cure of many diseases. This is especially true of the 
treatment of the Diseases of Women. What reliance shall be 
placed on manual operations, and what upon medicinal influences 
in curing them, is an unsettled question. There are those who 
insist that, in this specialty, surgery is almost omnipotent, and per 
contra those also who claim that constitutional remedies alone are 
adequate to the end in view. 

The attentive student of gynaecology is aware that within the 

last quarter of a century, Uterine Surgery has developed from a 

rudimentary to an almost perfect branch of 

Value of uterine surgery. . 

medical science. it has iurnished us with the 
most approved and available means of diagnosis, and with a mul- 
titude of resources for the relief and cure of certain diseases that 
were the opprobrium of medicine. It has fulfilled old indications 
with new and approved instruments, reconstructed the special 
pathology of sexual disease, and re-organized our aims and pur- 
poses and expedients in such a manner as to add very greatly to 
the comfort and welfare of woman. It has added another chair 
to the medical curriculum, augmented and improved our litera- 
ture, and developed a new and most useful specialty, which al- 
ready is more popular than any other, and which, at no distant 
day, bids fair to engross the attention and to appropriate to itself 
a large share of the medical talent of this and other countries. 

It was a very natural consequence of this rapid growth in the 
professional and popular favor that the claims set up for Surgery. 



Extravagant claims. 



412 LECTURES, CLINICAL AND DIDACTIC, 

as applied to the treatment of the Diseases of Women, should 
be somewhat exclusive and extravagant. Dr. 
Bennet frames his formula that ulceration and 
induration of the uterine cervix lie at the bottom of nearly all the 
diseases peculiar to the sex. Local cauterization will frequently 
remove these conditions — which he has been shrewd enough to 
confound in his writings, and therefore escharotics are specific. 
The generalization is the bait, the manipulation attracts, and the 
parade causes a premium to be placed on the operation. Forth- 
with his experiments and deductions are the text and the theory 
for an indiscriminate local treatment designed alike for all kinds 
of uterine affections and utero-visceral derangements. 

Sir Jas. Simpson incised the cervix as a remedy for obstructive 
dysmenorrhcea. Sims adapted his scissors as a uterotome, and 
improved upon the operation. The same oper- 
ation was soon recommended for the cure of 
sterilit}', and retro-flexion of the uterus. Then it was applied to 
the relief of the intractable uterine hemorrhage, and as a means 
of exploration and of facilitating excision in uterine fibroids. 
Now, in multitudes of cases, the uterine cervix is slit open, with 
every possible kind of result. The operation is a favorite one, for 
blood is shed, and there is some cutting in the dark, — which is 
always attractive in ratio with the risks that are taken. 

The various modifications and varied uses of the uterine specu- 
lum, the sound, the probe, the sponge and other tents, the explor- 
ing needle, the endoscope, and physical exploration by palpation, 
auscultation and percussion, have engaged the almost exclusive 
attention and confidence of uterine pathologists. Armed with 
these instruments, and aufait in using them for purposes of diag- 
nosis and of treatment, it is not at all strange that they have come 
to place an almost exclusive reliance upon them, and that the 
claims of a coincident and conservative thera- 
tiSi?y^noreT peuticsprac "P eutics should have been either overlooked or 
disregarded. They esteem the proposal to 
unite a course of medical with the surgical treatment of uterine 
ulceration, cervicitis, or endo-metritis, for example, as altogether 
superfluous — a species of superfcetation. When their resources 
are sufficient, and their work is substantially done, why propose 
to add anything, or to substitute it with what is less attractive, 



ON THE DISEASES OF WOMEN. 413 

flashy, seductive and sensational ? For, with all our boasting, it 
remains that, in this class of diseases, the operation of the best 
chosen internal remedies, is not and cannot be instantaneous. 
The relief they bring in chronic uterine and ovarian affections 
especially, comes only " after many days." They do their work 
quietly, and without any of the ad captandum eclat of a surgical 
exploit, or a sanguinary battle from the possible effects of which 
the patient may never recover. It is an axiom in midwifery that, 
whether natural or induced, the most rapid cases of labor are not 
the safest. In uterine surgery the risks are in ratio with the bold- 
ness and dispatch of the operator, which qualities are almost insep- 
arable from its employment. 

It is equally obvious that the disproportionate development of 
uterine surgery is due to causes that can be explained, and which 
are avoidable. Let me call your attention to a few of them. 

1. The groiuing scepticism in the minds of specialists concerning 
the effects and efficacy of internal medication. Providing he is edu- 
cated and thoughtful, the pursuit of a medi- 
me S dkation m respectIng cal specialty invariably inclines the physician 
to place less reliance, than does the general 
practitioner, upon constitutional treatment as a means of cure. 
The oculist and the aurist are not given to the common weakness 
of dosing their patients. Those who treat the diseases of the 
respiratory organs exclusively and most skillfully have more con- 
fidence in hygienic measures than in medicine. With every class 
of specialists, the higher the grade of their qualification, and 
the broader their field of observation, the lower their estimate 
of general treatment. For these men are sufficiently educated to 
discriminate and to differentiate. Their knowledge of physiology 
and of pathology assures them that, not only does every part 
suffer with the sick organ, or member, but that for the same rea- 
son, whatever lowers the general vitality will lessen the chances 
of recovery. 

Uterine pathologists necessarily reach a similar conclusion. Un- 
less their ideas of medicine, and of its capacity to cure, or to 

injure, are stereotyped and more or less anti- 
Abandonment of old ideas. 

quated, they gradually abandon the old thera- 
peutics, and learn to place a:i increased trust in modern surgery, 
with its topical expedients and its manifold resources. The 



414 LECTURES, CLINICAL AND DIDACTIC, 

cultivated gynaecologist of our day would as soon think of 
resorting to general blood-letting in hysteria, as to the use 
of emmenagogues in amenorrhea. When Dr. Thomas coun- 
sels that the bowels shall be left in a constipated condition in 
endo-metritis, it implies not only that he has a clear idea of the 
indications that are presented for the cure of that disease, but 
also that, in proscribing cathartics, he is interested in removing 
a fertile source of mischief in uterine complaints.* 

Without pausing to elaborate this idea, it must suffice to call 
your attention to the fact that the cultivation and practice of this 
specialty, as of every other, has had a two-fold result ; (1) it has 
stimulated a development of a special branch of surgery : and 
(2) it has impaired the general confidence in wholesale medica- 
tion for the cure of limited functional and organic disease. 

2. The natural preference which physicians, and their patients 

also, have for operative interference instead of internal treatment, 

whenever the former is possible. As compared 

Surgery more popular. . . 

with the surgeon, the physician labors at a 
great disadvantage. And the reward of his skill and patience 
are often disproportionate to the time and care bestowed 
on the cure of intricate and dangerous diseases. Although 
they may be equally skillful, each in his own department, my friend 
the professor of surgery will most likely gain more eclat by 
cutting off a limb, or excising a tumor, than my colleague in the 
chair of theory and practice will from curing a case of cerebro- 
spinal meningitis, Blight's disease, or of angina pectoris. All of 
which implies that we involuntarily place a premium on the 
manual operation, while it is such an ordinary affair for the phy- 
sician to tide his patient over his difficulties in a more quiet way, 
that but little relative stir is made concerning it. 

We do not criticize this propensity, although it has sometimes led 
to deplorable results. For it is impossible that such a large number 

of earnest and able workers should devote 
toIe e nejre l ct 1 e C d. ousht not their lives to the study and practice of uterine 

surgery without bringing it to a certain de- 
gree of perfection. And the more popular, the larger the field of 
experience, the greater the number of those who are competent to 

* A Practical Treatise on the Diseases of Women ; by T. Gaillard Thomas, M. D., 
etc., etc., Philadelphia, 1872, page 227. 



ON THE DISEASES OF WOMEN. 415 

practice it, the older the study, the more thorough its literature, 
the greater, better and more lasting will be the benefits conferred 
by it upon the profession and upon the race. 

But an evident result of this bias toward surgery is a neglect 
to cultivate and develop the curative sphere and relation of our 
remedies to the class of diseases under con- 
sideration. We study the special therapeu- 
tics of other ailments most carefully. It is not permissible 
to transfer them to the domain of a different branch of the 
healing art. Every species of clinical enquiry and analysis 
is entered upon and prosecuted with a view to the proper selec- 
tion of the remedy or remedies. The symptoms are balanced, 
the signs are translated into a familiar language, everything is 
made available, medically, to effect a cure through the opera- 
tion of the vital forces. 

If we could point to therapeutical results in gynecology which 
compare with those of uterine surgery, results which were as 
carefully obtained, as accurate and trustworthy 
in every particular, as critically analyzed and 
as readily available, our usefulness would be doubled, and the 
little world in which we now work as specialists would consist 
of two hemispheres instead of one. 

3. The comparatively limited opportunities and skill of those who 
have labored especially to develop uterine therapeutics. — The allure- 
ments to surgery, and its very general prac- 
sp?ci S a!fsI. antases ° f the tice among physicians and specialists, diminish- 
es the number of those who are laboring 
to define and determine the special therapeutics of uterine and 
kindred diseases. And the tendency of patients who are thus 
afflicted to estimate what is done for their relief and cure by the 
scale of suffering and risk at the hands of the doctor, lessens the 
number of those who are willing to trust and to wait for the 
results which might often be obtained by fitly-chosen remedies. 
Add to this that those of our physicians who are most competent 
to do this work are usually engaged in general practice, and it is 
leally no reflection upon their popularity, or their ability, to say 
that one reason why uterine surgery has outstripped uterine thera- 
peutics in the race, is because the opportunities and skill of those 
who practice the latter are comparatively limited. 



416 LECTURES, CLINICAL AND DIDACTIC, 

4. The bias towards harsh and harmful remedies whenever inter- 
nal means are employed. — There is a current idea which holds that 

when the internal generative organs of the 

A great error. . 

female are diseased, they require that stronger 
medicines should be given than in case of a similar disease 
which is seated in another organ or apparatus. This view 
is entertained by many who do not hesitate to acknowl- 
edge the wonderful delicacy of the nervous and vascular s}~mpa- 
thies of the uterus and its appendages. And yet they insist that it 
is sometimes necessary to medicate these patients very thoroughly 
before any benefit can be derived from remedies that have been 
taken internally. 

The consequence is that, becoming disgusted with such treat- 
ment, or afraid of it, these patients put themselves in the care of 
such doctors as will not dose them at all, but who will rely exclu- 
sively upon other means of relief. 

5. The theory that constitutional treatment is destined altogether 
to supersede surgery in the management of these sexual disorders. — 

Surgery is the complement of therapeutics as 

Surgery and therapeutics. . . 

one hand is of. the other, or the right eye oi 
its fellow. To assume that it is possible in all respects to 
substitute, or to supersede the necessity for either of them, 
would be like limiting the obstetrician to the use of but one 
hand, or the microscopist to that of one eye exclusively, and 
denying them the privilege of using the other under all circum- 
stances. The practical accoucheur is ambidextrous. And, if the 
microscopist uses but one eye at a time he alternates them. Each 
has its own sphere and function, and they must share the duty 
that is to be performed ; for, although one may be preferable to 
the other, according to idiosyncrasy, habit, education or circum- 
stance, still it remains that this dual arrangement is a part, and 
an indispensable part, of our organization as individuals. 

The same is true of the curative relations of medicine and sur- 
gery. Both are requisite, each in its proper place, but which shall 

be the more prominent will depend upon the 

Both essential. .... . /» 

peculiarities, habits and education of the phy- 
sician, and also, as we have shown, upon a variety of circum- 
stances. To declare that either of them is superfluous, and to 
declaim against its employment, very naturally excites a pre- 



OX THE DISEASES OF WOMEN. 417 

judice against those who talk and act so unreasonably. It is a 
question of boundary lines merely, and since the whole field 
belongs to us, we can shift the fences from time to time and 
cultivate the crop of expedients that will prove to be most 
valuable and useful. 

To compensate for this lack of interest in medicine as applied 
to the treatment of the diseases of women, it will be necessary, 

1. To have a series of new provings, on women, which shall be made 
ivith the greatest possible care and discrimination. — The health of 
woman is beset by so many contingencies, and 
a^sSy: ingsbyW ° man she is subject to such crises as to render it 
very difficult to find one who, both in her- 
self and her surroundings, is suited to become a prover; and 
the physicians who are really competent to superintend such a 
proving are perhaps equally rare. For, if such an index to the 
remedial relations of a drug shall be trustworthy, it implies that 
the physician who undertakes this labor is fully conversant with 
the whole range of uterine pathology ; that he has subjected his 
medicine to the test of a most searching examination ; eliminated 
all the symptoms which are naturally incident to menstruation, 
maternity, puberty, the climacteric, and also to her relations as 
wife and mother, to the church and to society, as well as to the 
distinctive susceptibilities that pertain to her sex, and which are 
so perplexing to all of us, and retained and classified only those 
symptoms which were unmistakably due to the action of the 
drug. 

The fact that this labor has not already been 1 perfected, and that 
it is a task of no small magnitude, should not deter those who 
hope for better things of uterine therapeu- 
iB^^knotilSS.' tics, from its faithful and persistent prosecu- 
tion. And I urge it upon you as members 
of this class to determine that you will add something to the com- 
mon stock of knowledge on this subject, something tangible and 
available, something that will be of service to those who are suf- 
fering, and which will prove that the pains you have taken in the 
study of special pathology and therapeutics have not been lost 
either to yourselves or to the profession at large. For, suppose 
that we had a full and complete proving of calcarea carbonica, or 
of sepia, or of any other remedy, made with particular reference 
27 



418 LECTURES, CLINICAL AND DIDACTIC, 

to the female organism, and under the eye of a skillful specialist; 
there. is no question that its influence for good would outweigh 
that which attaches to the invention of a new instrument, even 
if that instrument were as useful as the uterine sound. 

2. The most painstaking study of the differential diag?wsis of the 
diseases of the female generative system. — This condition is requi- 
site not only because it concerns the skillful 
treatment of these affections, but also because 
it bears a vital relation to gynecological literature. If he 
keeps them to himself, the physician's short-comings are self- 
limited ; but if he publishes his blunders, he perpetuates their 
remembrance and ensures their repetition. Therefore, he should 
know what he has done, as well as what he is doing. 

"With all due respect to those who have directly and indirectly 
contributed to our knowledge of materia medica, as it is applied 
to the diseases of women, it must be confessed 
that their labors would have been more fruit- 
ful of good if they had been better versed in uterine pathology 
and diagnosis. The clinical history of hundreds of cases that 
have been reported confirms the truth of this remark, and shows 
the need of culture in this direction. If every woman who 
takes a drug with a view to its physiological effects, were 
carefully examined, both physically and otherwise, before, 
during and af!:er making the "proving;" if she could be 
removed from all the vicissitudes which are certain to derange 
her sexual sympathies and to upset her health, the symptoms 
evolved and collected would be a better criterion of the range of 
action of the drug than we can otherwise obtain. And if every 
physician were fully posted in the matter of diagnosticating the 
contingent symptoms, or deviations from perfect health, which 
occur in most women (which, are necessarily transient and self- 
limited), and such as are really pathological and persistent, those 
which do not get well of themselves, and are not often cured, as 
well as those caused by emotional states, independently of our 
remedies, the value of our clinical record would be increased a 
thousand fold. 

This opens an avenue for usefulness and distinction ; for it is 
left for our school of practice to develop the medical side of this 



ON THE DISEASES OF WOMEN. 419 

question. We need such a chart of the remedial action, both 
pathogenetic and clinical, of medicines that 

And pathogenesis. . 

are suited to the female organism, as we 
do not at present possess. This is a sine qua non. It can 
not be obtained by the exclusive study of symptomatology 
after the old method, (1), because many of the resources 
of surgery are necessary as a means of determining whether 
or not the prover is in good health beforehand ; (2), without 

these facilities, we could not know the variety, 

And symptomatology. J 

extent, nature or seat of the lesions present in 
a given case, whether they are functional or organic, and there- 
fore our testimony concerning their cure could not be depended 
upon; and (3), it must be true of the tissues which compose 
the generative intestine, as it is of other textures, that they have 
their proper pathological and therapeutical, as well as their ana- 
tomical, physiological and surgical history and relations. 

MENOKRHCEA — CERVICAL EPISTAXIS. 

Case. — Miss M , 19 years of age, has been an invalid for 

four years past. She is not confined to her room except at irreg- 
ular intervals, but is active and able to ride or walk, and to some 
extent enjoy the society of her friends. She began to menstruate 
at fifteen. The first period came on with a great deal of pain and 
difficulty, but when the flow was finally established it continued 
for three weeks without cessation. After five days' intermission 
it commenced again, but without any considerable suffering. 
Again it continued until almost the end of the month, and again 
it returned with the regularity of the normal monthly discharge. 
In this manner, for four years, the flow has been almost constant. 
The longest interval in which she has ever been freefrom it,in all that 
time, is seven days. There is no dysmenorrhcea, the loss of blood 
is not excessive, but the flow is passive and painless, and continues 
when she is sleeping as well as during her waking hours. Some- 
times under strong mental excitement, as when she is at a concert 
or in company, and her mind is diverted, it ceases temporarily, and 
afterwards returns as before. The same effect has been observed 
in consequence of a carriage ride and of a journey by rail ; but it 
is of very short duration. 

If the flow is arrested, she suffers no inconvenience excepting 
a " rush of blood to the head," accompanied by more or less ver- 
tigo, headache, flushed face, dimness of vision, and a heavy, dull 
feeling, with disposition to sleep. At other times her mind is clear 



420 LECTURES, CLINICAL AND DIDACTIC, 

and her spirits are good. And yet she feels somewhat weakened 
and enervated by the constant loss of blood. Her appetite is 
good. There is no intra-pelvic pain or distress, no haemorrhoids, 
no constipation, and no urinary derangement. The only suffering 
noted is a feeling of aching and weariness in the region of the 
ovaries, more especially of the left one, at the month and after 
unusual exercise. During her whole menstrual life her mother 
was subject to a similar haemorrhage. 

This patient's general appearance does not indicate that she is 
ill. She has walked several squares to the Dispensary this morn- 
ing, with less fatigue than you would have supposed possible. 
Her color is somewhat heightened by the exercise in the open air, 
for her sister says that she is usually more pale than now, except- 
ing only when her haemorrhage has ceased and the blood rushes 
to her head. 

It is sometimes very important, in cases of this kind, to discover 

the relation which a passive uterine haemorrhage bears to the cata- 

menial function. If the flow dates from the 

Relation to menstruation. „ ' , , ,. , ,'»,,. « ,. , n 

rirst establishment 01 this Junction at puberty, 
as in this instance, or if it habitually ceases a short time before 
the "period," and then recurs regularly, you may conclude that 

it is essentially a menstrual disorder. There 

A diagnostic rule. . . 

are some exceptions to this rule, as m case 01 
medullary carcinoma, and sub-mucous polypi, and perhaps in 
syphilitic endometritis also ; but, in most instances, the manner 
and time of its advmt, and its regular periodicity afterwards 
(even although the period maybe longer or shorter than natural), 
are to be taken as evidence of its connection with the process of 
ovulation. 

Nor is it difficult to explain this result. The physiological in- 
jection of the endometrium, which is a condition of the menstrual 

secretion, is relieved and removed when the 

A physiological reason. . _ 

healthy woman has menstruated. .But, it she 
is not well, that extraordinary fullness of its vessels may continue, 
even although the menstrual flow has been discharged ; and there 
will remain a passive congestion of some portion of the uterine 
mucous membrane. This engorgement may relieve itself by a 
profuse and copious haemorrhage, as in menorrhagia, or even in 
metrorrhagia ; or it may pass away by a sort of cervical epistaxis, 



ON THE DISEASES OF WOMEN. 421 

or passive flow, in which the local excess of blood oozes out and 
escapes more leisurely. In the former case the critical and alarm- 
ing haemorrhage is sudden, and of short duration : in the latter it 
is a mere prolongation or continuation of the menses, without any 
very serious symptoms, until the month is nearly or quite spent, 
and it is time that they should return again. One is acute, active, 
and irregular in its recurrence ; the other chronic, passive, and 
distinctly periodical. 

There is another reason why this woman's haemorrhage, although 
so lonsr continued, must be classed as menstrual — a real case of 
menorrhcea. It is that the amount of the flow is 
not influenced by the exercise which she takes, 
or 1 y other circumstances, more decidedly than it is in ordinary 
menstruation. If that haemorrhage depended upon the presence 
of a sub-mucous or interstitial fibroid, a polypus, ulceration, can- 
cerous degeneration, or venous engorgement, the quantity of blood 
lost would vary with her habits. Above all things, it would not 
be lessened by riding and active exercise. 

Viewing this species of haemorrhage as in a sense critical, and 
remembering the " habit " which has grown out of its continu- 
ance, with brief intervals only, for years, we 

Its critical nature. 

should naturally expect that the arrest oi the 
flow would occasion more or less of suffering and disorder else- 
where. Hence the "rush of blood to the head/' of which this 
woman complains whenever the flow has ceased, and which sub- 
sides as soon as that flow is restored. The same cause will some- 
times induce a violent attack of facial neuralgia, or sick headache, 
vomiting, delirium, hysteria, spasms, coma, or even convulsions. 

To sIioav that this disease is not infrequent, and that the case 
before you is a typical one, I will read you some extracts from a 
letter received a few days ago from Dr. R. C. Sabin, of Wiscon- 
sin, a member of the class for 1871-72 : 

Case. — " My patient is now eighteen years of age. She com- 
menced menstruation at fifteen, and the flow has been almost con- 
stant ever since. The longest time in which she has been free 
from it is two weeks, when the interruption was caused by a jour- 
ney by rail. The discharge is of a bright red color, thin and 
watery, and has no odor. After continuing for a month or six 
weeks, the flow becomes stringy and thick, and then ceases for 



422 LECTURES, CLINICAL AND DIDACTIC, 

two or three days. Her health is always impaired at the time the 
flow stops, and there is giddiness, sudden flushes of the face, 
blindness, etc. These symptoms pass off as the flow returns. 
The urine is high-colored, and of a strong nauseous odor. 

"She is of scrofulous habit, short and fleshy, and is troubled 
with frequent moist eruptions. The constant drain does not seem 
to have the least effect in reducing her weight. She was ex- 
tremely fleshy as a child. Her general health seems good, she 
goes to school, and has a gooda appetite 

" She has taken, at different times, sepia, pulsatilla, calcarea 
carb., china,, hamamelis and ferrum. The latter benefits her gen- 
eral condition, and, temporarily, lessens the amount of the flow. 
Hamamelis will also check it in a few days, but then she feels 
wretched until the discharge comes on again." 

In these cases you should not fail to make a careful vaginal ex- 
amination before you venture an opinion concerning the nature 

of the disease, or the proper course of treatment 
ex?mma S tion° fphysical to be pursued. You may find the cervix uteri 

tender, swollen, congested, or in a state of are- 
olar hyperplasia ; or a small mucous polyp may have sufficed to 
perpetuate the mischief. Bi-manual examination, and the double 
touch, may discover such a state of ovarian irritation and inflam- 
mation as will account for the symptoms and give you a hint 
toward their relief. 

It is sometimes important to know whether this or other men- 
strual disorders have been hereditary in the patient's family. 

Especial inquiries should be made concerning 

Modifying circumstances. ,.,.,'. • p n • i ^ 

the hsemorrhagic diathesis, or if the patient has 
ever had chlorosis or anaemia. The clinical history of the case 
might also be modified if the woman had ever borne children, or 
been pregnant and suffered an abortion, and in some cases by her 
having nursed an infant. And so also by marriage, intemperate 
coitus, residence in a mountainous, a marshy, or an aguish district, 
by high living, and the free use of alcoholic drinks. For all these 
are so many avoidable causes of the disease under consideration. 
The fact that in this woman's history, as well as in Dr. Sabin's 
case, the haemorrhage has persisted for several 
S^SZSffiSgjS?. J ear s is proof that it may continue indefi- 
nitely, and without any very serious impairment 
of the general health. Its duration may even extend from 



ON THE DISEASES OF WOMEN. 423 

puberty to the climacteric, and then expire by limitation. Usu- 
ally, however, such persons survive the change of life with diffi- 
culty, for the arrest of the accustomed discharge is apt to induce 
disease of a more serious character elsewhere.' 

One of the most troublesome consequences of this form of uter- 
ine haemorrhage is sterility. Whatever the state of their general 
health, in women whose pelvic circulation is 
being thus constantly drained, the vitality of 
the internal generative organs is low. And even if ovulation is 
properly performed, the lining membrane of the generative intes- 
tine is not in a condition to favor conception. Moreover the san- 
guineous flow itself would be very likely, to interfere with a 
fruitful intercourse. Hence you will be consulted for the cure of 
barrenness which, directly or indirectly, is due to such a haemor- 
rhage as this woman has had for the past four years. 

Treatment. — In the whole range of medical practice, I scarcely 

know of a class of cases which is better suited to illustrate the 

efficacy of properly chosen internal remedies, 

Medicine versus Surgery. .. .. .. .. 1 .. . 

conjoined with suitable hygienic regulations, 
than this. Here is a case of haemorrhage which depends upon a 
pathological disorder of one of the most prominent of all the 
bodily functions. It has a definite clinical history. Its symp- 
toms are significant. Its causes are obvious and avoidable. Its 
diagnosis and prognosis are not difficult. Its treatment is similar 
to that of other diseased conditions. And it can be cured by 
therapeutic means exclusively. 

In all these respects such a case as the one before you differs 

from uterine haemorrhage accompanying or following labor or 

abortion, or from habitual and excessive losses 

Not to be confounded with f }}i ooc [ i n consequence of intra-uterine 

unavoidable haemorrhage. J. 

growths. In them the haemorrhage is acci- 
dental and more or less dangerous. It is a mere contingency. 
and must be relieved at once, or the patient's life may be sacri- 
ficed. The simple expedient of emptying the womb and securing 
its contraction may be sufficient. But in the passive form of uter- 
ine haemorrhage, connected with menstruation, surgical appliances 
are either powerless or harmful, and no such very general indica- 
tion is presented. We are forced to depend upon uterine thera- 
peutics. 



424 LECTURES, CLINICAL AND DIDACTIC, 

In the selection of a remedy, or remedies, we should not over- 
look the significance of certain incidental states or conditions, for 
example, the different dyscrasiae, each of which 

General therapeutics. . , „ . , . . , -■ . rr , 1 

is possessed ot its own clinical bearing. 11ms : 

If the patient is predisposed to haemorrhage, such remedies as 

china, ipecacuanha, sabina, platina, secale cornutum, ferrum, nux 

vomica, natrum mm., hamamelis, trillium, 

For the haemorrhagic r i lus tox., calcarea carb., belladonna, crocus, 

diathesis. ' ' 

carbo veg., phosphorus, arsenicum alb., and 
sulphuric or nitric acid may be indicated. She should be put 
upon cool acidulated drinks, and enjoined to keep as quiet as pos- 
sible during the first week or ten days of the period especially. 

If she is in a state of chloro-anaemia, the remedy must cover the 
symptoms which are most prominent. Among them you will ob- 
serve such as signify a profound impression , of 

For the chloro-ansemia. . _ 

the nervous and circulatory, as well as ot the 
digestive and menstrual functions. And, whether the haemor- 
rhage is the cause or the consequence of the impaired quality of 
the blood, the case will have to be treated as one of chlorosis with 
serious complications.* 

In case of confirmed scrofulosis with menorrhoea, I apprehend 
it to be of the utmost importance to attend to the plrysiological 

needs of the organism in advance of medication. 



For the scrofulous First, select a suitable diet, one that can and 



will be assimilated. It should consist of a 
proper and available proportion of the oleo-albuminous elements. 
These should be cooked and presented in a pleasant and palatable 
form, and at a suitable time of the day. The appetite should be 
encouraged by mental diversion and suitable exercise in the open 
air. For the function of haematogenesis, or blood-making, to 
which the lymphatic glandular apparatus is especially devoted, 
must proceed properly, else the quality of the blood will become 
so seriously impaired that haemorrhage will almost certainly 
follow. 

The most prominent remedies suited to this cachexia, and the 
symptoms that are likely to spring from it in this form of cervical 
epistaxis, are calcarea carb., calcarea phos., hepar sulphuris, sili- 
cea, baryta carb., jodium, phytolacca, carbo veg., mezereum, mere. 

* See page 103 of this volume. 



ON THE DISEASES OF AVOMEN. 425 

sol., mere, jod., sulphur, and the nitric, muriatic or sulphuric 
acids. 

In some obstinate examples of this form of passive uterine 
haemorrhage (if your experience accords with mine), you will find 
that when the most carefully selected remedies 
cachlx£ e syphilitic have failed, as they sometimes do, you will suc- 

ceed in curing it by giving medicines which are 
anti-syphilitic in their character. In this way the kali joclatum, 
kali hyd., thuja, mere, praecip. ruber, and nitric acid, in such po- 
tencies as you shall select, may help you out of the difficulty. Of 
course, if you succeed by giving them upon the theory that there 
was a slight taint of syphilis in the lesion, it will not be either 
prudent or necessary to tell the patient or her friends why this 
particular class of remedies was chosen. 

Ovarian disease is so frequently at the bottom of these hemor- 
rhagic complaints that you should be very careful not to overlook 
it. For, as a rule, the ovaritis precedes the 

For ovarian complications. itp-i 

haemorrhage, and is the cause both 01 its long 
continuance and of its periodical return. This is especially true 
if the chronic and unnatural flow dates from puberty. The reme- 
dies which are best adapted to the cure of this complication are 
belladonna, colocynth, hamamelis, lilium tig., lachesis, carbo veg., 
conium, veratrum vir., platina, mercurius corr., and pulsatilla. In 
a word, the cardinal symptoms that properly belong to the lesion 
of the ovaries, when the ovaritis and the haemorrhage co-exist^ 
are a more trustworthy guide in the selection of the remedy than 
the quantity, or even the quality, of the sanguineous flow itself. 

Since it is possible that a change of climate may aid in the re- 
covery, one who has lived in a mountainous region may be sent 

to a different section ; or one who has resided 

Change of climate. . 

in a low, marshy district, may be transferred to 
the mountains. Sometimes a cure will follow a change from 
the prairies to the sea-side, or vice versa, the object being to bring 
about an entire renovation by a change of external conditions. 
Or a sea-voyage, or salt-water baths, may prove very beneficial. 
While it is requisite that such patients as Miss should take 

sufficient exercise, it is equally important that 

Suitable exercise. x ° x 

they should not overdo. Horseback riding, or 
running the sewing machine, skating, or dancing, for example, 



426 LECTUEES, CLINICAL AND DIDACTIC, 

would aggravate or increase her disorder. The exercise should 
be more gentle and passive. 

I have more confidence in nitric acid, in the second decimal 
dilution, than in any other single remedy in 

Nitric acid. . „ 

these cases. It is not, however, specific, She 
will take it four times daily, and report the result. 



EIBEO-CYSTIC TUMOE OF THE UTERUS. 

I will, close this lecture with a few remarks upon the case of 
fibro-cystic tumor of the uterus, which I had before the class in 
the hospital last week. 

Case. — Mrs. C. D , aged 31 years, English, first observed 

an enlargement in her right inguinal region of about the size of 
an orange, ten years ago. This tumor did not appear to grow at 
all until after her marriage, which was two years since. She 
very soon became pregnant, and the tumor increased in size in 
proportion with the development of the gravid uterus. After 
her delivery at term, the growth was observed by the plrysician, 
who expressed his surprise that a second child did not follow the 
first. She weaned her baby when it was thirteen months old, 
since which time the enlargement has increased more rapidly, un- 
til the abdomen is enormously distended. 

Mrs. D. has menstruated regularly and normally since weaning 
the child, and has never been subject to haemorrhage. The 
uterus is in situ, the sound passes to the depth of three inches 
onl} T , and the mobility of the organ, independent of the abdomi- 
nal tumor, is clearly recognized. The wave-line is observable, 
and all the signs are those of an ovarian cyst. 

This case, you will remember, was diagnosticated as one of 
ovarian dropsy. The next day my colleague, Prof. Danforth cut 
down upon the tumor in your presence. Adhesions were found 
upon all sides, and throughout its whole extent. When these 
were finally broken up, its separation effected, and the tumor 
turned out, it was found to be attached by a slender pedicle to 
the right side of the body of the uterus, very near its fundus. 
You remember that tapping the mass with a Spencer Wells' 
trocar failed to bring away any fluid. The pedicle was ligated, 
and the tumor, which weighed twenty pounds, removed as in the 
cases of ovariotomy which have been performed before the class 
during this session. 



ON THE DISEASES OF WOMEN. 427 

Here, then, was an error in diagnosis, for which I am respon- 
sible. I confess the fact, and, contrary to the cnstom of most 
teachers, propose to tell you how it happened 

An error in diagnosis. . , , 

to be made, and how you can avoid such a mis- 
take in the future. 

When I found that the uterine cavity was not enlarged, and that 
the sound, although it reached the fundus uteri, would pass only 

three inches ; and was assured by the patient 

Deceptive symptoms. ill i i • . j. i 

that she had never been subject to haemorr- 
hage, it was very natural and proper to exclude the possibility 
of the growth being either a sub-mucous or an interstitial fibroid: 
and when, with the sound in utero and my hand over the abdo- 
men, I found that it was possible to move the womb considerably 
without changing the position or relations of the tumor in the 
least, I felt warranted in deciding that the growth was not uter- 
ine at all. For, even if it were a sub-peritoneal fibroid, its mobility 
should be consentaneous, or synchronous, so to speak, with that 
of the uterus ; while in this instance the uterus was moveable, 
but the tumor was not. 

The fact that this unusual state of things existed, and the rea- 
son why this important differential sign between uterine and other 
tumors failed in this instance, was easily explained after the 
operation. The pedicle was three inches or more in length, 
slender, and well defined. The tumor was firmly bound by ad- 
hesions on all sides. The length, form and location of the pedicle 
would have allowed the uterus to be moved quite freely with- 
out moving the tumor, even if the adhesions had not glued it so 
securely to the neighboring parts. 

Dr. Atthill, in speaking of the diagnostic value of the mobility 
of the uterus independently of the tumor in these cases, says, 
" Still even here error is possible, for if a fibrous tumor spring 
from the uterus by a moderately long pedicle, or even by a short 
one, we may be able to move the uterus to such an extent as to 
lead to the conclusion that it is free, and on the other hand it is 
possible that in a case of ovarian disease the uterus might be so 
bound clown by adhesions as to be immovable.* 

In most fibro-cystic tumors of the uterus the cysts are small. 

* Clinical Lectures on the Diseases Peculiar to Women, by Lombe Atthill, M. D., 
etc., Dublin, 1871. 



428 LECTURES, CLINICAL AND DIDACTIC, 

The fluctuation felt through the abdominal parietes is therefore 
deceptive. The wave-line is not pathognomonic of ovarian dropsy, 
for you are witnesses that it existed in this case, and yet there 
was no ovarian disease of any kind. Its occurrence was also ex- 
plained by what happened during the operation. When my 
colleague opened the peritoneal sac, it was found to contain a 
layer of ascitic fluid, which could not gravitate from the anterior 
parietes of the abdomen on account of the adhesions. Sub- 
peritoneal fibroids are seldom single, and when there is more than 
one the margin of each can be more readily mapped out, and the 
probable character of the growth determined beforehand. 

In review of this case, therefore, I do not see how it would be 
possible for one to say positively that the symptoms present were 
those of a uterine fibroid and not of ovarian 
timis^mp^we 1 ! some " dropsy. In other words, the differential diag- 
nosis between these two affections (especi- 
ally in case of a single fibro-cyst) is, in the present state 
of our knowledge, imperfect and impossible. In exceptional 
cases we can not tell one from the other, until after the explora- 
tory incision is made. 

An interesting case of this kind was related to me by Dr. B. R. 
Westfall, of Macomb, Illinois. I will read you from his notes : 

"November 30, 1868. — Was called to see Mrs. S , aged 

thirty-two years, then in her second labor. Noticing that the ab- 
domen seemed unusually large, I placed my 
hand over the abdominal parietes, and found 
two distinct tumors of about equal size, which, during the con- 
tractions of the uterus, were sufficiently separated to enable me 
to trace the boundaries of each. Supposing the one to be an 
ovarian tumor, I questioned the patient to ascertain if she had dis- 
covered it. She said she had discovered both tumors in a few 
months after conception, and supposed that she would be deliv- 
ered of twins. She had never felt any pain or other discomfort 
to lead her to suspect any disease. The labor progressed and ter- 
minated successfully. Recovery was as rapid as usual. I exam- 
ined the tumor frequently afterward, and found each time that it 
was rapidly shrinking. After three months I could find no trace 
of it. 

wi In October, 1870, I was called to examine my patient again, 



ON THE DISEASES OF WOMEN. 429 

as she was satisfied she was enceinte, and that the tumor was again 
being developed. I found it situated to the left of the uterus as 
before, and of about equal proportions with it. It continued to 
grow in the same ratio with the foetus. No inconvenience was 
felt, except that the weight was unpleasant when she was upon 
her feet. Her subsequent labor and convalescence were as satis- 
factory as before, but the tumor did not decrease in size as rapidly 
as it had done before, and never entirely disappeared. The small- 
est it became was about the size and shape of a goose-egg. It 
remained for some time in statu quo. 

" October 20, 1871. — Nine months after parturition, menstru- 
ation returned, and the tumor began to enlarge, and at each pe- 
riod to grow perceptibly. The growth was sudden, being most 
marked a few days before the menses were due. Fifteen months 
after its birth the child was weaned, and from this date the en- 
largement was still more rapid, until she has attained the size of 
a woman at the seventh month of gestation. 

"January 10, 1872. — It being determined to resort to ovari- 
otomy, the attending surgeon, who had diagnosticated the pres- 
ence of a cyst, made the incision, and, upon inserting a trocar, 
failed to bring away any fluid. The tumor proved to be a fibroid. 
The woman died thirty hours after the operation." 

If this same error had not been frequently committed by men 
of large experience and professional acumen, I should have felt a 
greater annoyance with the result in Mrs. D.'s case. Spencer 
Wells says: "It is very difficult — perhaps impossible — to dis- 
tinguish between a multilocular ovarian cyst and a fibro-cystic 
uterine tumor when the cysts are large and the connection with 
the rest of the uterus is elongated. I removed one such tumor, 
which some men of great experience took to be ovarian. The 
cyst held twenty-six pints of fluid. The seat of pedicle connect- 
ing it with the uterus was three to four inches long, and the 
uterus moved quite independently of the tumor. Indeed, it was 
not until I came to divide the pedicle that I knew what I had to 
to deal with." 

Dr. Charles C. Lee cites a case of fibro-cystic uterine growth 
which was mistaken for ovarian dropsy, in which the womb w * was 
perfectly movable on the sound, without imparting the slightest motion 
to the abdominal tumor." Indeed, in Dr. Lee's essay on the Diag- 



430 LECTUKES, CLINICAL AND DIDACTIC, 

nosis of Ovarian Tumors from Fibro-cystic Tumors of the Uterus,* 
you will find the particulars of eighteen, cases, which although 
they had been diagnosticated as ovarian, proved, upon the section 
and separation of the growth from its peritoneal attachments, to 
be extra-uterine. 

Spencer Wells has, in some cases, been able to diagnosticate a 
fibro-cyst of the uterus from ovarian dropsy by obtaining on para- 
centesis a thin serum which contained from five to fifteen per cen- 
tum of blood. These were so intimately mixed that they would 
not separate until the fluid had been allowed to stand for some 
hours. But this particular fluid is not always or often obtained 
upon tapping. For according to Kceberle, in the uterine fibro- 
cyst it may be either yellowish, thin, serous and rich in lymph, 
or cholestrin, or brownish, muddy, sero-purulent or bloody. All 
of which signifies, that, as a distinguishing symptom, and separately 
considered, this sign is of no more value than the others. 

* New York Medical Journal, vol. xix, p 452. 



ON THE DISEASES OF WOMEN. 431. 



LECTURE XXVI. 



aphthous ulceration of the os and cervix uteri. 

Gentlemen : 

This patient's clinical history will afford a good text for some 
remarks upon a form of uterine ulceration which, although it is 
not a very common, is nevertheless a very troublesome affec- 
tion. 

Case. — Mrs. S , forty years 'of age, the mother of four 

children, has been ill for eighteen months past. She is pale, and 
has the worn look of one whose strength has been exhausted either 
by a drain of the vital fluids, or from inanition. She has a slight 
leucorrhcea, but the discharge bears no relation to the month, and 
from her description appears to be exclusively vaginal. There is 
at times much burning in the vagina, and at the neck of the 
womb. This is aggravated by standing a long time, or by riding. 
It is also apt to be worse in the evening. Sometimes there is 
strangury, but it is of brief duration and not very severe. There 
is not a great deal of inter-pelvic pain and distress. Her appetite 
is poor and capricious. Her food " does not appear to do her any 
good." Her nervous system is shattered. She cannot sleep, is 
exceedingly anxious about her children, and, in short, a nothing 
goes right any more." On examination the vagina is found to be 
considerably inflamed, hot and dry, and the anterior lip of the 
uterine cervix to be the seat of an aphthous ulcer, which is twice 
the size of the thumb nail. The only treatment she has had was 
a four months' course of bi-weekly cauterizations, from which her 
health became so bad that she was obliged to stop taking them. 

This form of uterine ulceration begins with a slight vesicular, 
or herpetic eruption, which is located upon the cervix. The 
vesicles, which are as delicate as those of vari- 
cella, soon burst, the epithelium becomes de- 
tached, and small curd-like spots appear. With a pencil-brush 
these spots can be easily removed, and the denuded surface re- 
mains a bona fide ulcer. If a number of these vesicles coalesce, 



432 LECTURES, CLINICAL AND DIDACTIC, 

they finally develop into an extensive patch of ulceration. Some- 
times the ulcers are small, yellow and of regular outline ; again 
they are much larger, with an inflamed base and an irregular 
ragged outline. Now and then the serum discharged from the 
vesicles is so acrid and excoriating as to inoculate the neighboring 
surfaces. 

The chief characteristics of the aphthous ulcer, however, are its 

shallowness, its being preceded and accompanied usually by the 

herpetic eruption on the cervix uteri, and the 

Symptoms. 

repeated attempts and iailures to reproduce the 
proper investing epithelium. The surface of this ulcer, as seen 
through the speculum, is half concealed beneath an abnormal in- 
vestiture, which is constantly being exfoliated and reproduced. 
In this respect it resembles the aphthous ulcer of stomatitis, and 
like it, is an evidence of a depraved state of nutrition, a kind of 
scorbutic cachexia. 

The diagnosis is very important, for it has very much to do 
with the treatment and conduct of the case. The only forms of 

uterine ulceration with which this is liable to be 

Diagnosis. _ . . 

confounded are the diphtheritic and the sj^phi- 
litic. From the diphtheritic ulcer it may be known by the deli- 
cate and imperfectly organized structure of the membrane that 
covers the ulcer, which in respect of its color and thickness, is 
very different from the wash-leather deposit in diphtheria. The 
attendant constitutional symptoms are much more grave in diph- 
theria than in an ordinary case of aphthous ulceration. 

The syphilitic ulcer is of a dark, red hue, and never bright or 
yellow, and the general constitutional symptoms are wholly dif- 
ferent from those which are incident to the aphthous form of 
uterine ulceration. 

The principal causes of this disease are defective nutrition, an 
impoverished state of the blood, chlorosis, 

Causes. . . 

tabes mesenterica, chronic gastritis or gastro- 
enteritis, and the exhausting processes of gestation and lactation. 
The treatment is very simple, and if properly chosen, very suc- 
cessful. Much depends upon the correct diagnosis of the difficulty. 

Such cases are sometimes cured unwittingly, 

Treatment. . . ° J 

and neither the doctor nor the patient knows 
what has been done. More frequently, however, they are made 



ON THE DISEASES OF WOMEN. 433 

worse by the treatment adopted. This result may often be as- 
cribed to the fact that physicians do not always discriminate as to 
the particular variety of ulceration with which they have to deal, 
and that the means chosen are inappropriate, too harsh, and there- 
fore harmful. It is not at all unusual for the simplest cases of this 
kind to run along for months, and finally, for them to be nearly 
or quite sacrificed upon the altar of a promiscuous cauterization. 

Let me tell you, gentlemen, that in the whole range of our art, 
I do not know of any temptation to compare with that which 
sometimes prompts and permits the physician to diagnosticate and 
to pretend to cure the most serious uterine diseases when they 
have no real existence. Patients not unfrequently declare them- 
selves ill with some particular " weakness," and, whether they 
are mistaken or not, will insist upon being treated therefor, either 
at our hands or by another. The fashion is to gratify them, and 
to put a premium upon every kind of local expedient especially. 

Thousands of women have thus been cauterized for uterine 

ulceration which, before the application of the escharotic, had no 

existence. Multitudes of them have done 

Reprehensible practice. , . 

penance by wearing pessaries, and supporters 
of every description for luxations of the womb that could not be 
found, except in their own imagination, or in that of the physician. 
They have been bed-ridden and abused until the weakness of the 
sex has become a by-word and a reproach, mainly because the 
doctors have been too anxious to " make out a case ;" and after- 
wards, because they have seen fit to persecute them with the most 
harmful appliances. 

The doctor who treats a broken leg or a case of small-pox must 
be skilled in diagnosis, and measurably honest. His selfishness 
may prompt him to make his patients as many visits as possible, 
and to extort a fabulous fee for his services ; but, concerning the 
nature of the accident, or of the ailment in question, there is little 
relative opportunity for him to deceive the sufferer or the friends. 
But when he is consulted in the case of a woman who is supposed 
to be ill with a sexual infirmity, the conditions are changed. He 
makes his diagnosis in the dark, as it were, and who shall dis- 
prove it ? His professional opinion is not open to criticism, nor 
his skill to a healthful competition. And hence the peculiar 
temptation, in this department of our calling, to those members 
28 



434 LECTURES, CLINICAL AND DIDACTIC, 

of the profession who have a bias towards dishonesty, and who 
seize upon every opportunity to make the most out of a class of 
cases which are often obscure, intricate and tedious at the best. 

Bennett and a host of lesser lights have decreed the uterine 
cervix to be the center of pathological interest in woman. Too 
many physicians make it the focus of pecuniary interest, and 
therefore punish it through personal cupidity and a lack of con- 
science, as well as of knowledge. 

Here is a poor woman whose local disease is the sign and seal 
of a constitutional cachexy. She is ill from her head to her feet. 

Her whole organism is deranged. A few little 
merely^YoSrdifeiT n(>t vesicles were developed upon the neck of her 

womb. Their investing tunic was ruptured, 
and an aphthous ulcer was the consequence. That ulceration has 
perpetuated itself, because the general condition from which it 
came has not been cured. A moment's reflection will satisfy you 
that cauterization is contra-indicated. For even if its effect were 
locally beneficial, and not injurious, it could do no good in a gen- 
eral way. The cause would remain, and the consequence would 
repeat itself. 

A more skillful, and successful method of cure in these cases, 
is to set about correcting the vitiated condition of the system, 

precisely as you would in a case of stomatitis 
helkh r ° ve the general niaterna.* You may order a diet consisting 

chiefly of the nitrogenous principles. Beef, in the 
form of steak or broths, oyster-soup, the whites of eggs, and 
milk, are preferable. To correct the strumous habit, the vegeta- 
ble acids are also necessary. Baked apples, peaches, grapes, 
oranges, or lemonade, are almost always grateful, and, I believe, 
useful in such cases. Where patients have foresworn tea and 
coffee, I have sometimes prescribed that they should resume their 
use, with a view to arrest the too rapid metamorphosis of tissue 
which is going on. 

For the first or vesicular stage of this disorder, and in old cases 

where a new crop of vesicles appears from time 

For the vesicular stage. . ... 

to time, cantharis, rhus tox., or aurum muriati- 
cum, are usually sufficient. 

* See page 218. 



ON THE DISEASES OF WOMEN. 435 

If there is also an aphthous condition of the mouth and of the 

alimentary mucous membrane, you may find it 

tion° r the aphth ° us condi " nec essary to prescribe arsenicumalb., hydrastin, 

nux vomica, belladonna, mercurius jod., or the 

nitric or sulphuric acid. 

Locally, I think it a good plan, in this form of uterine ulcera- 
tion especially, to use the same remedy that is administered inter- 
nally. It can be applied with water, or glycer- 

Local treatment. . t -i i i t . n * 

me, or both these substances as a vehicle. A 
very simple and available injection consists of adding a table- 
spoonful of glycerine to as much castile suds as will be needed 
for one application. In addition to the medicines already named, 
the coptis trifolia, borax, kali bichromatum, and of late years, the 
carbolic acid in weak solution, deserve to be mentioned in this 
connection. If the suppuration is very considerable, as it some- 
times is, calendula injections may be used with advantage. Where 
there is chronic vaginitis, with profuse leucorrhcea, and desquama- 
tion of the vaginal epithelium, whatever variety of injection is 
chosen, may be brought in contact with the entire mucous mem- 
brane of that canal through such an instrument as this, which is 
a cylindrical speculum, that is perforated with numerous holes of 
the size of a large shot. For the herpetic form of this disease, 
Leadam recommends the injection of a weak solution of the thuja 
oc, to be repeated two or three times daily. 

The objection to the topical use of astringents, as for example, 
tannic acid, alum, and the acetate of lead, in cases of this kind is 

that they do not possess any especial and spe- 

^Objections to astringents, cificaUy cumtive relation t O the disease itself ; 

and also that they are extremely liable to cause 
such a modification of the circulation as shall tend to involve the 
menstrual function, and thereby to complicate the case. 

We will give Mrs. S arsenicum alb. 3, a dose three times 

daily. Her diet will consist of bread and milk with beef, potatoes 
and tomatoes, for dinner. Once each day she 
will drink a glass of good fresh lemonade ; and 
she will not let the day pass without going to walk or ride a lit- 
tle in the open air. She will also use the injection of castile suds 
and glycerine every night and morning.* 

*In four weeks this patient was well. She took no other remedies. 



436 LECTURES, CLINICAL AND DIDACTIC, 



DIPHTHERITIC ULCERATION OF THE OS UTERI. 

In this variety of uterine ulceration the constitutional symp- 
toms correspond with those which are present in diphtheria, affect- 
ing other portions of mucous membrane, as for 

Constitutional symptoms. .. 

example, the nasal and respiratory passages. 
There is the same evidence of blood-poisoning, the same prostra- 
tion and attendant phenomena, and the same sequelae that occur 
when the throat is the seat of the abnormal deposit. 

Examination per vaginam reveals an ulcer upon one or both lips 
of the cervix, which is covered, or nearly so, with a heterol- 
ogous deposit. This deposit or pseudo-mem- 

Physical symptoms. . . 

brane is a foreign growth, which, in due time, 
exfoliates. In some cases instead of one or two large-sized 
ulcers, there are a number of small, whitish, shining patches, 
which vary in size from that of a split pea to half a hazel-nut. 
These patches may, or may not, coalesce. To the " touch" they 
impart a rough or dry sensation that is quite peculiar, and very 
different from the feel of other ulcers. 

The pseudo-membrane which covers the diphtheritic ulcer, or 
patch, is at first very adherent, and cannot be detached without 

more or less injury and consequent haemorrhage. 

After a little while, however, the friction of 
the parts during the motion of the body, as in walking or sitting 
upright, or a careless introduction of the finger, or of the specu- 
lum, may separate them. Their removal leaves a raw, bleeding, 
painful, intractable, suppurating ulcer, which may, or may not, 
extemporize another wash-leather covering for itself. According 
to Becquerel, in the order of their coming, the formation of these 
false membranes precedes the development of the ulcer, or diph- 
theritic chancre. It is only while something of the covering 
remains that these ulcers can be diagnosticated with absolute cer- 
tainty. 

As a rule the larger the surface of the diphtheritic ulcer, the 

more superficial it is ; and per contra, the 
and^h^dSdir/g? 6 uker ' smaller its dimensions, the greater its depth. The 

deeper the ulcer, the more profuse the discharge. 
Sometimes the flow therefrom is acrid and corrosive, and as in 



ON THE DISEASES OE WOMEN. 437 

nasal diphtheria especially, it destroys, or perhaps inoculates the 
adjacent tissues. This discharge is always fetid, and, when it is 
obtained directly from the ulcerated surface, emits the peculiar 
diphtheritic odor. True diphtheria may be produced in other per- 
sons by inoculation with this virus. 

Diphtheritic ulceration of the os uteri is rarely an idiopathic 

affection. The throat and other parts are generally first attacked, and 

afterwards the vulva, vagina and neck of the 

A secondary disease. . ,.,.., 

womb. As m syphilitic ulceration, the superior 
vagina and cervix are less frequently the seat of the lesion than 
are the inferior vagina and the vulva. It has been remarked that, 
as in other forms of diphtheria, this species of uterine ulceration 
is especially liable to occur during the epidemic prevalence of va- 
riola, rubeola and erysipelas. Many obscure affections of the gen- 
erative system have undoubtedly resulted from prolonged exposure 
to diphtheria, and the fatigue of nursing those who were ill with 
that disease. In these cases the utero-vaginal mucous membrane 
has probably been the seat of diphtheritic inflammation and ulcer- 
ation, where nothing of the kind was suspected. 

If the diphtheritic ulceration of the os and cervix uteri takes 
place during pregnancy, it is very likely to cause abortion ; if 
during the lying-in state, it may invade the uterine cavity, in 
which case pseudo-membranous patches have been found at post 
mortem lining the uterus itself. 

Dr. Tilt reports a case in which he claims that a patient had a 
diphtheritic ulcer of the os uteri from leech-bites. But, in order 
to produce a generic ulcer of this kind, it is 
necessary that the specific cause should be at 
work. For this specific agency, whatever it may be, is just as 
requisite in this case as it is in diphtheritic angina or conjunctivitis. 
The only cases of diphtheritic ulceration of the os uteri and the 
vagina which I have seen have occurred in the persons of those 
women who, from watching and taking care of those who were ill 
with diphtheria, became predisposed to this form of the complaint 
and took it in this way. It is possible, and even probable, that 
some previous disorder of the generative system, in each of these 
cases, may have caused the lesion to locate itself upon the uterus 
rather than in the throat. During the prevalence of an epidemic 



438 LECTURES, CLINICAL AND DIDACTIC, 

of diphtheria you should examine this class of patients very care- 
fully with the speculum. 

The treatment need not differ essentially from that proper for 
other forms of diphtheria. If any one remedy deserves more 
prominent mention than another, it is cantharis. 
And this not only because of its frequent indi- 
cation in the treatment of other varieties of diphtheria, but also 
on account of its special curative relation to the cervix uteri. 
Mercurius jod., kali bich., kali brom., phytolacca, nitric acid, jo- 
dium and hepar sulphuris may be of great service under their 
especial indications. 

Locally, injections of the tincture of hydrastis, or calendula, or 
of any of the aforenamed remedies, diluted with water, or glycer- 
ine, or both, are sometimes very serviceable. 
If the discharge is very fetid and offensive, the 
chlorate of potassa, in the proportion of half a drachm to four 
fluid-ounces of distilled water, and used in the same manner, an- 
swers a good purpose as an antiseptic. And so also does a weak 
solution of carbolic acid, of kreasote, or of the permanganate of 
potash. The objection to the potash salt is on account of its 
color. My friend, Dr. W. H. Holcombe, has made use of the kali 
bichromicum, in the strength of half a grain of the crude drug 
dissolved in a tumbler of water, " as an injection for ulcerated os 
uteri, and even for leucorrhcea, with good effect." This may also 
be used for the relief of diphtheritic ulceration and of vaginal 
diphtheritis. 

PELVIC CELLULITIS. — PEKI-METRITIS. — PELVIC ABSCESS. 

I will now show you a case of pelvic cellulitis. This patient 
comes from the woman's ward of the hospital, where she has been 
under my care for a week past. The following is her clinical his- 
tory, as it was noted by the Resident Physician, Dr. Chas. Adams : 

Case. — Mrs. S , set. 30, was delivered by forceps of a dead 

child twelve weeks ago. Following this her physician said that 
she had puerperal fever. When she entered the hospital she 
complained of acute pain in the right iliac region, which was ag- 
gravated by touch and motion. There was a tumor (for which 
she had been blistered) in the right iliac fossa, which was of 



ON THE DISEASES OF WOMEN. 439 

irregular outline, and could be very plainly felt above the brim 
of the pelvis. The corresponding limb was retracted. She could 
not lie upon that side. She had diarrhoea, with black, shiny 
stools. She complained of cramps in the uterine region on going 
to stool. Burning during micturition. Emaciation. Pulse 85, and 
weak. Tongue coated. Yesterday she commenced to have a 
pretty free discharge of pus from the uterus, and her symptoms 
are already somewhat relieved. Until then the vagina was hot, 
dry and very sensitive. The tumor could be recognized by the 
" touch," located at the right side of the cervix uteri in the roof 
of the vagina. 

Synonyms. — This disease has received several names which 
only serve to confuse the mind. Thus, among its synonyms are 
pelvic cellulitis, peri-uterine cellulitis, perimetritis, parametritis, 
pelvic abscess, intra-pelvic abscess, abscess of the uterus, inflamma- 
tion and abscess of the broad ligaments. The term peri-uterine 
cellulitis, proposed by Dr. Thomas, as locating the lesion more 
definitely, and implying that this is one of the sequelae of uterine 
disease or accident, is perhaps least objectionable. 

You are aware that the pelvis is lined with a fascia which is re- 
flected over the muscles contained within it, and over the pelvic 
organs also, and which serves to shield, to 
'strengthen and to separate them. Now be- 
tween the layers of this pelvic fascia, when they come into con- 
tact with each other, and also between the fascia and the organ 
which it covers or separates from another organ, there is inter- 
posed a quantity of loose cellular tissue. This tissue is particu- 
larly abundant between the folds of the broad ligaments, about 
the abdominal portion of the uterine cervix, between the uterus and 
the bladder, about the urethra, in the recto-vaginal septum, and in 
the recto-sacral space. There is considerable discrepancy among 
authors concerning the presence of this areolar tissue between 
the peritoneum and the uterus itself, a majority insisting that 
there is so little of it there as scarcely to be worth mentioning. 
Hence there are those physicians who insist that peri-uterine cel- 
lulitis proper is a kind of mythical disorder — one of the refine- 
ments of uterine diagnosis. 

But I apprehend that there is no real conflict between the au- 
thority of the anatomist on this point, and the experience of the 
gynaecologist, when he finds that attacks of inflammation are 



440 LECTURES, CLINICAL AND DIDACTIC, 

sometimes seated in the areolar tissue about the uterus. For this 
form of the disease is especially incident to the 

An important suggestion. 

puerperal state. And when we remember the 
changes that take place in the other uterine textures in conse- 
quence of conception, I can see no reason to doubt that there is, 
during pregnancy, a corresponding growth and development of its 
cellular tissue also. Authors have not, in so far as I am aware, 
said anything on this subject. Nevertheless it may be true that 
this particular tissue, like the muscular coat of the womb, is pro- 
duced and then removed to answer certain very important physi- 
ological ends ; and that this consecutive development and decline 
constitute a predisposing cause of cellulitis as one of the con- 
tingents of labor, whether premature or at term. At any rate, I 
give you the hint as one that contains something practical. 

Peri-uterine cellulitis, therefore, is an inflammation of the con- 
nective tissue about the uterus and within the pelvis. As I have 
said, when it is not traumatic, it rarely occurs 

Frequency of. . 

except as a sequel or contingent ot lying-m. 
Gestation and labor are, therefore, its most powerful predispo- 
nents. The disease is less frequent than puerperal peritonitis 
and phlebitis, but is probably more common than many practi- 
tioners have supposed. (Exit the patient.') 

Authors divide this disease into three, but I shall specify four 
stages. The first is that of congestion, the second of effusion, the 
third of absorption or resolution, and the fourth 
of suppuration. I add the stage of resolution, 
because I believe that appropriate treatment will sometimes en- 
able us to cure our patients without allowing the disease to pass 
on to the suppurative stage. 

The First or Congestive Stage. — The congestion may set in ab- 
ruptly a few hours after delivery, or it may be delayed until some 
days or even weeks have passed, and then may 
come on insidiously. The symptoms are such 
as mark the onset of inflammatory fever. There is a more or less 
decided chill, which may or may not be repeated. If the chill is 
lacking, it will be substituted by rigors, which are sometimes 
painful and persistent in ratio with the exhausted and debilitated 
condition of the patient. The febrile re-action is very decided. 
The heat of the skin is often intense, the pulse full, strong and 



ON THE DISEASES OF WOMEN. 441 

rapid, or, in weak subjects, quick, frequent and irritable. The 
tongue is furred, and not unfrequently there is nausea with dispo- 
sition to emesis. 

These symptoms are accompanied, or followed almost immedi- 
ately, by intra-pelvic pain and distress. The location of this pain 
varies with the seat of the inflammation. If 

Intra-pelvic pain. , -it 

the cellular tissue between the broad ligaments 
is attacked, the pain will be referred to the corresponding side of 
the pelvis, in which it will be deep-seated and very severe. If the 
same tissue surrounding the uterine neck is the seat of the lesion, 
the suffering will be in the upper part of the vagina, and contact 
with this organ, even by the exercise of the most delicate "touch," 
will be insupportable. If the peritoneum is also inflamed, the 
pain will be acute and lancinating in character. Most of the pain 
experienced, however, is ascribed to the pressure of the effused 
fluid (which has escaped into this tissue) against the neighboring 
organs. In many cases the bladder, and in others the rectum, are 
thus mechanically pressed upon, giving rise to strangury and 
tenesmus, which are not relieved by the usual remedies. Very 
often, more especially after the tumor caused by the effused serum 
has been formed, the pain is described as throbbing and paroxys- 
mal. It is usually not diffuse, but local and circumscribed in its 
extent. In acute cases the congestive stage is limited to a few 
hours. 

The Second or Stage of Effusion. — As in peritonitis or pleu- 
risy, the period of effusion generally follows in pretty rapid suc- 
cession. The serum escapes from the capilla- 

Formation of the tumor. . pi t • • m 

ries into the meshes of the areolar tissue, infil- 
trates it, and solidifies as if it were out of the body, or just as it 
does in the pulmonary air-cells when it causes a hepatized state 
of the lung in pneumonia. The resulting tumor varies in its 
shape and size according to circumstances. If the space between 
the fascise is limited and of a particular shape, the " swelling " 
cannot be larger, and must be of the same configuration. It 
grows rapidly until it has attained its maximum size, becoming 
more and more firm and dense, or perhaps softer, in its structure. 
If the patient is in a weak, adynamic state, however, the clot will 
not be firm, and the tumor will remain flaccid, or become softer, 
in some such manner as it does in pelvic hematocele. In many 



442 LECTURES, CLINICAL AND DIDACTIC, 

examples the tumor is exquisitely tender to the touch, but again 
it is not so. 

In the majority of cases of peri- uterine cellulitis, the tumefac- 
tion is situated in the lateral portion of the pelvis. You may find 
it in one or the other of the iliac regions. And 

Location of. . . 

its presence is best made out by means ot the 
bi-manual exploration. The index finger of the right hand being 
introduced into the v agina for the purpose of examining the os and 
cervix uteri, as well as the cul -de - sac of Douglas, the iliac 
region is examined at the same time through the abdominal pari- 
etes with the other hand. Between the two the size, shape and 
consistence of the tumor, whether it be above the pelvic brim or 
below it, can be pretty accurately determined. If there are any 
remaining doubts, the finger may be introduced into the rectum, 
and so much of the posterior and lateral walls of the womb as are 
within reach may also be examined. As a rule the uterus is fixed, 
or but slightly movable. 

One of the first symptoms indicative of this effusion is a local 
heat, swelling and tenderness of the vagina, which is apt to be 

felt at one side of the canal, and limited to one 

Symptoms. . . 

spot. Later the vaginal wall covering the tumor 
becomes thickened and indurated. It may, or may not, remain 
sensitive. 

If the tumor develops in either iliac fossa, the corresponding 
limb will usually, but not always, be flexed. This retraction of 
the thigh relieves the pain by relaxing the muscles in the imme- 
diate vicinity of the tumor. It is involuntary, and more or less 
complaint will be made when the leg is distended. 

In puerperal women the milk and lochia are usually suppressed. 

This complicates the case, and implicates the nervous system more 

especially. Delirium, insomnia, unrest, spasms, 

Incidental symptoms. . 

convulsions, and even mania have iolloweo. irom 
this cause. In rarer cases there is retention of urine, and still 
more rarely an almost total suppression thereof. Vomiting is a 
frequent accompaniment of pelvic cellulitis, possibly, as Dr. Att- 
hill suggests, because of the endo-metritis which generally co- 
exists. 

This stage of effusion, with its resulting tumor, may continue 
unchanged for a variable period ranging from one week to a 



ON THE DISEASES OF WOMEN. 443 

month. There is no fixed limit to its duration. Sometimes, in con- 
sequence of a relapse, the congestion is again 
established, and the resulting effusion follow- 
ing, there is an increased pouring out of serum and a marked and 
sudden growth of the tumor. Again the inflammation being pas- 
sive, the tumor becomes insensibly larger. Or it may develop in 
the right iliac fossa, and when some considerable time has elapsed, 
commence to grow and finally attain a marked development in the 
left one. Successive tumors of this kind occurring in the same 
locality, are by no means rare. 

The Third /Stage, or that of Resolution. — The stage of absorp- 
tion, or of resolution, is that in which the tumor may remain for 
some time at a stand-still, and finally pass away 
without ending in suppuration. As you will 
infer, if for any reason, as for example because of a depraved 
cachexia, great debility from previous illness, inanition or excessive 
medication, the patients' vitality is very much reduced, the reso- 
lution of the swelling would be impossible, and suppuration would 
almost inevitably follow. Under the circumstances, therefore, in 
which we are likely to find these patients, this third stage of the 
disease will frequently be lacking altogether. 

But when her strength has previously been good, her gestation 
and labor have been accomplished without too great a draught 
upon her nutritive and nervous resources ; 
res C o?mion? nsthatpromote when she has been well nursed and properly 
fed, medicated and otherwise cared for; and 
above all when there is no prevalent epidemic erysipelas, or puer- 
peral disorder, we may observe the tumor gradually and quietly 
resolving itself away under appropriate treatment. If the swell- 
ing consists of effused serum, and not of coagulable lymph, it 
may be more readily absorbed. 

The Fourth, or Suppurative Stage. — If left to itself, however, 

or mal-treated, and in a majority of cases almost inevitably, the 

tendency of this disease is to terminate in suppu- 

Symptoms of. . 

ration. With the commencement ol this pro- 
cess the symptoms vary as in the case of abscesses located else- 
where. If the pain and tenderness have subsided, they are very 
apt to return. The tumor may become extremely sensitive again, 
and motion, or the pressure upon the tumor caused by an attempt 



444 LECTURES, CLINICAL AND DIDACTIC, 

to stand upon the feet, to urinate, or while at stool, may occasion 

extreme suffering. The limb cannot be extended. The patient's 

body is flexed in the bed. A species of hectic 

Accompanying; hectic. . 

lever, 01 a remittent type, sets in. lhere are 
rigors alternating with great heat, and evening exacerbations of 
fever, which sometimes mislead the physician. When she sleeps 
there is a profuse and exhausting perspiration, as in the worst 
cases of phthisis. The face and skin are pale. The countenance 
assumes the expression which surgeons recognize as characterizing 
that pus has been formed somewhere in the body, and is awaiting 
its discharge. The pulse continues rapid, although it has lost in 
strength. There is anorexia and great debility, with or without 
diarrhoea. 

Even although the tumor may have been firm and like fibro- 

cartilage, or almost like scirrhus, to the touch, it now begins to 

soften. This softening may be recognized either 

Seat of the fluctuation. o «/ o 

by abdominal or vaginal palpation, or by both 
combined. It may occur gradually, or develop itself more rapidly. 
The weaker the patient the less the resistance to this process, and the 
more speedy the resulting fluctuation. This fluctuation is in most 
cases observable at the upper part of the vagina at one side of, or 
directly behind the cervix uteri, in the posterior cul-de-sac. 
" From some peculiar arrangement of the layers of the pelvic fas- 
ciae, when pus is formed in the course of a pelvic cellulitis, occur- 
ring in the upper half of the true cavity of the pelvis — and this, 
you must remember, is the most frequent seat of the disease — it 
has a tendency always to point in this direction and to find an exit 
for itself, either at the lower base of the broad ligaments, or in 
the posterior cul-de-sac of the vault of the vagina ; and it is at 
these spots, where the fascial layer seems to be unusually thin and 
weak, that the feeling of fluctuation is ordinarily first detected."* 
Now this fluctuation may be due to the presence of effused 
liquor sanguinis, or of pus. But if the disease has persisted, as 

in the case before us, for a considerable time, 
diagnosis f the presence and been attended by the inflammatory fever, 

followed by the hectic, the copious perspiration 
after sleeping, and the frequent, irritable pulse, you may be rea- 
sonably assured of the presence of pus in the tumor. 

*Clinical Lectures on the Diseases of Women, by Sir J. Y. Simpson. D. Appleton 
& Co., New York, 1872, page 72. 



ON THE DISEASES OF WOMEN. 445 

Concerning the means of escape for the pus, when it has been 

formed, it is important to remember that it may extemporize an 

outlet for itself through the bladder, the uterus, 

Its varied means of escape. . . 

the vagina, or the rectum. It it forms at the 
superior strait, it may gravitate, and, running down along the 
course of the muscles, may pass beneath the pelvic fasciae, and 
escape with the femoral vessels, so as to point near the groin. 
Sometimes it passes backwards through the great ischiatic fora- 
men, and forms an abscess in the region of the hip ; or it may 
even point at the great trochanter of the thigh bone. In rare 
instances it perforates both the uterus and the bladder, and leaves 
a fistula between them. Still more rarely, perhaps, it discharges 
into the cavity of the peritoneum. In seventy cases of puerperal 
pelvic cellulitis, Dr. McClintock, of Dublin,* found that thirty- 
seven ended with suppuration and the discharge of pus. Of these 
twenty -four were opened externally, or burst, of which twenty 
were discharged from the iliac region, two above the pubis, one 
in the inguinal region, and one beside the anus. Six others found 
an outlet through the vagina, five through the anus, and two 
burst into the bladder. 

With respect to the essential nature of this disorder, I have 
long held and taught the idea set forth by Virchow, that, in reality, 
it is a species of erysipelas. Its clinical history, 
ceUuS. ialnature ° fpelvic its epidemic prevalence, and its special thera- 
peutics, correspond with those of erysipelas, 
more closely than with any other disorder. It is quite probable 
that many cases of this disease have been mistaken for puerperal 
peritonitis, and that the propagation of this latter malady by cer- 
tain fomites is really to be explained upon the 
siplir^ 1 ^ 11 ^ 10 ^" theory of the inoculability of the erysipelatous 
poison as in the case of phlegmonous erysipelas. 
Causes. — I have already reminded you that pelvic cellulitis is 
one of the contingencies of lying-in. It may follow in conse- 
quence of injuries sustained in natural unassist- 

Parturition. . 

ed labor. One of its most frequent causes is 
the traumatic injury of the cervix uteri by pressure of the pre- 
senting part, especially of the head, during delivery. In abortion 

* Clinical Memoirs on the Diseases of Women. 



446 LECTURES, CLINICAL AND DIDACTIC, 

it may follow a similar injury to the neck of the womb. For this 
reason it is comparatively frequent where abortion has been in- 
duced by means that are almost necessarily harmful. Women 
have sometimes brought it on themselves in this way. 

Puerperal cellulitis is one of the sequels of instrumental deliv- 
ery, more especially when the resort to the forceps and other in- 
struments has been unwarrantably delayed, 

A sequel to dystocia. 

when they have been rgnorantly or carelessly 
used, and when the patient has not received the proper attention 
and nursing after their employment. These causes are more effi- 
cient in proportion with the debilitated and depraved condition 
of the patient's system, and also with her proneness to scrofulosis, 
phthisis, and even to certain acute diseases, as, for example, pneu- 
monia and erysipelas. 

The non-puerperal cellulitis may result from the forcible intro- 
duction, or the prolonged retention, of the sound and the 

sponge or other tents. The wearing of intra- 
sufge C r°y ntingentofuterine uterine pessaries, even the best of them, 

is very apt to induce it. Incision of the 
cervix uteri, whether for the cure of obstructive dysmen- 
orrhcea, for the removal or arrest of development of fibroids, 
or even for the arrest of uterine haemorrhage, is not an in- 
frequent cause. It has followed amputation of the cervix, 
ovariotomy, the ligation of polypi, the excision of hsemorr- 
hoidal tumors, the operation for vesico- and recto-vaginal fistulas, 
and also that for ruptured perineum. It has also resulted from 
the use of very severe escharotics, as the potassa cum calce ; the 
wearing of vaginal pessaries for a long time without removal ; 
excessive and too forcible coitus ; and the extension of corporeal 
metritis and ovaritis to the areolar tissue about the uterus, and 
between the layers of the broad ligaments. 

Coincident Diseases. — Peri-uterine cellulitis rarely runs its 
whole course without being more or less complicated with other 
diseases. This is true, indeed, of most of the ailments for which 
you will be called upon to prescribe. The lines that separate 
pneumonia from pleurisy, or rheumatism from neuralgia, for ex- 
ample, are much more distinct and clear in the books than you 
will find them to be at the bedside. So you will most frequently 
observe that this form of cellulitis is more or less confounded with 



ON THE DISEASES OF WOMEN. 447 

pelvi-peritonitis, ovaritis, and endometritis, in which case its clini- 
cal history and symptoms will be modified accordingly. 

Diagnosis. — This fact complicates its diagnosis. If you are not 
more skillful than your predecessors, you will sometimes be puz- 
zled to differentiate between pelvic peritonitis, 

Sometimes very difficult. . -. .. .. . 

pelvic hsemotocele, uterine fibroids and pelvic 
cellulitis. Let me beg your earnest attention therefore, while I 
tell you how you may know them apart. 

The pelvic areolar tissue being between the layers of the broad 
ligaments, and beneath the outer coat of the uterus, both of which 

structures are composed of reflections of peri- 

From pelvi-peritonitis. . 

toneum, it may be supposed that in case of in- 
flammation of either of them, the symptoms must necessarily be 
very distinct, not to say pathognomonic, in order to be recognized. 
As a rule, the pain in the first stage, prior to effusion, is less acute 
in cellulitis than in pelvi-peritonitis. In the former, if the exu- 
dation of the liquor sanguinis is copious, the suffering is increased 
by it ; while in the latter, as in pleurisy or synovitis, the effusion 
is followed by a mitigation, if not by an entire remission of pain ; 
which may return, but which, from that time forward, is less 
acute and altogether changed in its character. 

In most cases of cellulitis the tenderness, pain and local heat 
are referred to and commence in the iliac fossae. The same is true 
of puerperal ovaritis, in which the peritoneal investment of the 
ovary becomes inflamed during lying-in. But in the former the 
pain does not change its location, nor does it incline to become 
diffused over the abdomen, both of which symptoms are proper to 
ovaritis occurring in puerperal women. 

I have copied Dr. Thomas' table, giving the differential signs 
between peri-uterine cellulitis and pelvi-peritonitis, upon the 
blackboard :* 

PERI-UTERINE CELLULITIS. PELVIC PERITONITIS. 

1. Tumor easily reached, generally found i. Tumor, if discoverable, very high, only 
to one side of the uterus, and may be in vaginal cul-de-sac, does not extend 
felt above the pelvic brim ; above the superior strait ; 

2. Tendency to suppuration ; 2. Suppuration less common ; 

3. Abdominal tenderness chiefly over one 3. Abdominal tenderness excessive above 

iliac fossa ; brim of the pelvis ; 

*. A Practical Treatise on the Diseases of Women. By T. Gaillard Thomas, M.D., 
etc, Third edition, 1872, page 461. 



448 LECTURES, CLINICAL AND DIDACTIC, 

PERI-UTERINE CELLULITIS. PELVIC PERITONITIS. 

4. Tumefaction generally noticed later- 4. Generally noticed near or upon the 

ally in the pelvis ; median line ; 

5. Tendency to monthly relapses not 5. Tendency to relapse every month 
marked ; very marked ; 

6. Retraction of thigh not rare ; 6. Retraction of thigh rarely occurs ; 

7. Pain severe and steady ; 7. Pain excessive and often paroxysmal ; 

8. Facies not much altered ; 8. Facies very anxious ; 

9. Nausea and vomiting not excessive ; 9. Nausea and vomiting often excessive ; 

10. Does not necessarily displace the 10. Displaces the uterus as a rule ; 

uterus ; 

11. Uterus fixed to a limited extent ; 11. Uterus immovable on all sides. 

The statement of some of these signs needs to be qualified. If, 
for example, the inflammation in cellulitis were always limited to 
the broad ligament on either side, the tumor could invariably be 
reached without difficulty by downward pressure in the corre- 
sponding iliac fossa. But the fact is that it has no such constant 
seat. It may happen that the connective tissue surrounding the 
inferior segment of the womb, or about the cervix uteri, shall be 
inflamed, while that which separates the layers of the broad liga- 
ment escapes altogether. In this case we should fail to find the 
tumor at the superior strait, but might detect it per vaginam or 
by the rectum. In exceptional instances of pelvic cellulitis, it is 
impossible to locate the tumor at all. 

Peritonitis is more directly related to disorders of menstruation, 
and to the return of the monthly cycle, than cellulitis. The com- 
mencement and brief continuance of the peritoneal pain in the 
median line, and the absence of a marked tendency to suppura- 
tion, will generally enable you to separate this disease from pelvic 
cellulitis. Owing to the extension of the inflammation in this 
form of peritonitis, the induration, if there is any, is not always 
located in the median line, as the pain was at the beginning of the 
attack. When gonorrhceul, or, indeed, ordinary inflammation, ex- 
tends from the uterine cavity through the Fallopian tubes, and 
invades the abdomen and the pelvis, it is more likely to give rise 
to peritonitis than to cellulitis. You should not forget that, while 
pelvi-peritonitis is quite a common affection with non-puerperal 
women, pelvic cellulitis almost never occurs excepting among 
those who have recently been confined. 

It must be acknowledged, however, that the lines which sepa- 



ON THE DISEASES OF WOMEN. 449 

rate these two diseases are not always distinct. For, whether it 
be due to the fact that the textures involved 
are contiguous, and that these lesions frequently 
co-exist, or that our present means of differentiation are imper- 
fect, it remains that they may be combined without our knowing 
it, and that we are liable occasionally to mistake one for the other. 
Although pelvic cellulitis and pelvic hematocele are both of 
them most frequent after delivery, yet the conditions of the 
patient's general system upon which they are 

From pelvic hematocele. 

prone to occur are very dirterent. lnus, pelvic 
hematocele takes place in consequence of a weak, adynamic state 
in which the blood has become of bad quality by extreme losses, 
as in uterine .hemorrhage, or from the rupture of one or more 
small vessels during labor. It is also incident to the hemorrhagic 
diathesis. Neither of these conditions pertain to the etiology of 
pelvic cellulitis. 

In pelvic hematocele the formation of the tumor is not pre- 
ceded by local congestion, and symptoms proper to the first stage 
of an acute inflammation, as in cellulitis. It comes on suddenly, 
and is accompanied by signs of prostration, sinking and collapse. 
The tumor in hematocele varies in its consistence, but is never 
hard and ligneous to the feel, like that of cellulitis. The more 
impoverished the blood, the softer the tumor. In cellulitis, the 
tendency toward suppuration causes the swelling to become softer 
as it grows older. The opposite change occurs in the hemato- 
matous tumor, which gradually becomes harder than it was orig- 
inally. 

Uterine fibroids come on insidiously and grow very slowly. Un- 
til they occasion trouble mechanically they are neither sensitive 
nor do they cause pain in the womb or the adja- 

From uterine fibroids. . . , 

cent parts. It sub-mucous, or interstitial, they 
are characterized by the frequent occurrence of metrorrhagia, and 
inter-periodic hemorrhage, which is not a contingent of cellulitis. 
The tumor, in case of fibroid, is firm and not oedematous to the 
feel, and there is no tendency in it toward suppuration. Fibroids 
do not render the uterus immovable, as the tumor in cellulitis 
often does. 

In case, however, that you can not otherwise decide as to the 
nature of the pelvic tumor, you may pass the exploring-needle into 
29 



450 LECTURES, CLINICAL AND DIDACTIC, 

it from its vaginal surface. If you bring away a drop or two of 
pus upon the instrument, it is a positive sign of abscess ; if blood 
only, and that of a dark, purplish color, it may be a case of hem- 
atocele ; and if no specimen of any kind of abnormal product is 
obtained, the negative symptom will satisfy you that it is probably 
a case of uterine fibroid. This is an excellent means of diagnosis 
and may really be a great blessing in your hands. For the safety 
of your patient, as well as of your own reputation, will depend 
upon your skill in diagnosis. 

Sequelce. — The most common sequel of this form of cellulitis is 
pelvic abscess. It often happens that the evacuation of the tumor 
a single time will not suffice. In many cases 
these abscesses continue to discharge for months 
and even for years. The accompanying symptoms vary with the 
location of the tumor and its means of outlet. Incredible quan- 
tities of pus are poured out, and the patient's strength and vitality 
are so undermined that her health may be ruined thereby. 

Another result of this disease, which is frequently entailed 
upon those who have had it, is sterility. It is not unusual for a 
' woman to lose her first-born in consequence of 
a difficult labor, to have cellulitis in child-bed, 
and to recover her health in every respect, except that in future 
she remains barren. In this case the cellular inflammation has 
caused the function of reproduction to be suspended. This fre- 
quently happens as an indirect result of criminal abortion. 

Menstruation is sometimes most seriously implicated, either 
because of ovarian complications, with cellulitis, 

Menstrual disorders. . . „. 

or from some partial or complete obstruction or 
the Fallopian tube or of the cervix uteri. 

Other sequelae include certain uterine displacements, and the 
vesico- or recto-vaginal tistulse which are sometimes caused by 
sloughing of the septa between the bladder, or the bowels and 
the vagina. 

Prognosis. — The prognosis should be cautiously made. If it is 
possible to secure the resolution of the tumor, and to prevent seri- 
ous relapses, the patient will probably recover. 
coTcurKntdi 1 sease dItior and Much will depend, however, upon the general 
strength and vitality. If these shall be very 
much reduced, the case is less promising. So also with the 



ON THE DISEASES OF WOMEN. 451 

chronic and incurable disorders of digestion with which it may be 
complicated. But you should not despair of cuiing even the 
worst attack, provided the patient is not already moribund, and 
you can supply certain physiological requisites for her recovery. 
If the disease is epidemic, the prospects are less favorable. If 
it occurs in the winter or spring months, during stormy and in- 
clement weather, when erysipelas, diphtheria, 

The epidemic tendency. . .. 

scarlatina, or dysentery, and kindred diseases 
are prevalent, it subtracts so much from the chances of recovery. 
Those cases which arise from traumatic injury are generally more 
grave than such as are referable to more ordinary causes. 

If the disease invades other organs, as when the pus that has 
formed finds an outlet through the uterus or the bladder, it may 
prove fatal through the serious complications that follow. If the 
abscess discharges into the cavity of the abdomen, the patient will 
be ^very apt to die suddenly. 

The janitor's bell, which is as inevitable as one's shadow, has 
overtaken us. I will speak of the treatment of pelvic cellulitis at 
my next lecture. 



452 LECTURES, CLINICAL AND DIDACTIC, 



LECTURE XXVII. 

PELVIC CELLULITIS (CONTINUED), 



Gentlemen 



At the close of the last lecture I had finished my remarks on 
the special pathology of peri-uterine cellulitis. In illustration 
of the fact that this disease may run an erratic course, and finally 
develop into pelvic abscess, and that physicians are prone to err 
in its diagnosis, I will read you the notes of a case which is still 
under treatment. The report was taken verbatim from the 
patient's mouth : 

Case. — I am twenty-eight years old, and was confined two 
years ago with my first and only child. I had enjoyed perfect 
health during pregnancy, excepting a soreness of one of my 
breasts, which was occasioned by my own imprudence. My labor 
began at seven o'clock in the evening, and lasted until one o'clock 
the next morning, when I was delivered of a dead child. I was 
under the care of a midwife who gave me some powders, a little 
wine, and free draughts of cinnamon tea, in order to hasten the 
pains, which she thought were too slow. From ten p.m. to one 
o'clock A.M., I had one continual pain, and was finally delivered 
in the standing posture. The child which, two hours before its 
birth had been alive, was a very large one. 

For some days after delivery I lost a great deal of clotted and 
very offensive blood. I had pains low in the sides and groins 
almost immediately, and, five days afterwards was taken with a 
very severe chill, which was followed by a burning fever. The 
milk disappeared twenty-four hours later. The flow became yel- 
lowish and watery, instead of bloody. A physician was called, 
who decided that I had puerperal fever. He prescribed medi- 
cines to control the fever, and ordered vaginal injections of water 
containing carbolic acid. At first I seemed to improve, but in a 
few days the pain in the sides returned. The doctor examined 
me internally (with a speculum), and said that I had ulcers on 
the neck of the womb. He burned them twice a week for about 



ON THE DISEASES OF WOMEN. 453 

six weeks with the nitrate of silver, but, before they were cnred, 
I was taken one morning with severe cramps in the bowels, which 
lasted the whole day, and were followed by chills and fever. 
These cramps came every two or three days, and were very pain- 
ful. The doctor ordered paregoric, and afterwards laudanum. 

In the middle of the following May I was compelled to change 
my residence. My ride in the carriage was a very painful one, 
and in a few days I was worse than ever. I began to have a 
severe and steady pain in the left side of the bowels, low down 
(iliac region), and the doctor, after another examination, declared 
me to be threatened with an ovarian tumor and hardening of the 
left ligament. A greenish ointment was applied over the whole 
side of the abdomen, and the swelling gradually disappeared, but 
the ligament (Poupart's) has always remained hard. I took at 
that time a great deal of iron, and of the iodide of potash, con- 
tinuing it until my stomach could support it no longer. 

In the summer a diarrhoea, with straining, and a pain which 
continued after each passage, set in. This lasted for many months 
and left my bowels in a very weak state. I, however, improved 
gradually, and finally the doctor ordered me to go out of doors. 
Walking was difficult and painful. In August, while in the open 
air, I caught a severe cold, and became very sick again, with 
cranrps in the stomach and bowels, vomiting and diarrhoea, with 
dreadful straining. Another physician was called in counsel, and 
I was said to be in great danger. They said I had a commencing 
peritonitis, with great swelling of the womb and general inflam- 
mation. 

The end of September came before I was able to be up again, 
but the diarrhoea and pains continued, and made me so weak and 
wretched that, in the following January, I resolved to try Homoe- 
opathy, and accordingly sent for Dr. S****. Within a month the 
diarrhoea and pain ceased entirely, my appetite returned, and I 
gained flesh and strength. I felt so much better, indeed, that I 
accepted a proposition to go to Europe. But toward the middle 
of March, I began to feel considerable pain in the right side (iliac 
region), which, until that time, had been well. These pains soon 
became so severe that I lost all rest. Nothing unnatural could 
be seen or felt in that locality. The pains were of a tearing char- 
acter, and extended from the right hip through the groin to the 
knee. All the pains which I had suffered before were as nothing 
compared with these. For six weeks I never slept without taking 
the hydrate of chloral, a very little of which sufficed. 

Dr. S. thought my suffering was due to neuralgia, and, believ- 
ing that the sea-air would most probably cure me, advised me not 
to abandon the idea of going abroad. Consequently, although I 
had noticed two small lumps in my left groin, as they were not 



454 LECTURES, CLINICAL AND DIDACTIC-, 

painful, I paid no attention to them, and left Chicago for New 
York in the latter end of May. The journey proved very hurtful, 
the lumps increased in size, and I was compelled to take to my 
bed almost immediately after my arrival in New York. 

The first of June Dr. F***** came to see me, and after a thor- 
ough examination told me that I had no sign of ever having had 
an ovarian tumor, that the glands were swollen, that my sickness 
would be tedious, but that, with proper care, he thought I would 
recover. He did not wish to frighten me by saying that I 
already had one or more abscesses. 

The first of these abscesses was opened by the doctor on the 
eighth day of June, and the second a week later. Even after they 
were discharged, moving in the bed was very difficult, and walk- 
ing quite impossible. The flow of pus continued profusely for. 
about a month, and, having given up the proposed voyage, I was 
not well enough to return to Chicago until the twelfth day of 
July. Dr. F. feared lest the journey by rail might determine an- 
other abscess, but it did not seem to do as much harm as it had 
done before. 

Arrived at home, I placed myself under the care of Dr. R. 
Ludlam, and although I still suffered severely at times, I was able 
to get up and to sit in an arm-chair before the fire. Walking was 
still difficult, and I abstained from it. The Great Fire came early 
in October, my house was burned up, and it was expected that it 
would prostrate me entirely ; but in this we were agreeably disap- 
pointed, for I never felt so well as for about six months after- 
wards. One abscess (orifice) closed entirely, and the other 
almost ceased to discharge. 

At the end of March I began to experience a return of the old 
pains in the left side, which were attributed to my having walked 
too far in making an excursion down town. I had chills and 
fever, and the doctor feared that another abscess would form. 
Three weeks later an abscess pointed just beneath the scar formed 
by the first one. It was lanced, and discharged, but less freely 
than before. In all other respects, excepting this local trouble, I 
am well. 

In addition to the symptoms which this patient has detailed so 

intelligently, others were elicited on physical examination. While 

this last abscess was forming, the " touch " 

Further symptoms. „ , , . „ 

revealed a swelling or about the size 01 a 
pullet's egg in the left vaginal cul-de-sac. This tumor was 
somewhat soft and very sensitive, so that when I pressed upon 
it my patient felt inclined to faint. The left border of the uterus 
and of the cervix were tumefied and puffy, or (Edematous. The 



ON THE DISEASES OF WOMEN. 455 

Douglas' cul-de-sac felt thickened, indurated, and less supple 
than natural, giving the impression that (probably at the time 
she experienced the severe tenesmus of the boAvel) there had 
been a retro-uterine tumor also. The vagina was hot and dry. 
Con'oined manipulation, with pressure in the left iliac fossa, 
could not be borne. The peri-rectal tissue was also indurated. 
The bladder and urethra appeared to have escaped implication. 
Abdominal palpation was not painful. The uterus was forced to 
the opposite, or right side of the pelvis (right latero-version), 
a displacement which might explain the prolonged and severe 
attack of neuralgia from which she had suffered more than a year 
before. 

I must not omit a reference to the fact that in this case the two 
first abscesses discharged above, and the last one below Poupart's 
ligament. She is taking calcarea carbonica 3 , morning, noon and 
night. 

Treatment. — It has been said that practically it is not a very 

serious matter to be able to form a correct diagnosis between 

pelvic cellulitis and the diseases which so 

inferences based on cor- c i 0S ely resemble it. But, gentlemen, I am of 

rect diagnosis. J 7 o ? 

a very different opinion. For, suppose a physi- 
cian should tell you that it was of very little consequence to him 
whether his patient had the pleurisy or the erysipelas, and that 
the treatment was substantially the same, no matter what the 
name of the disease, what would you say of him, and what would 
be the measure of your trust in him as a skillful and successful 
practitioner? And if we expect him to discriminate between 
pleurisy and erysipelas, why should he mot also, when it is pos- 
sible, separate peritonitis from erysipelas ? In other words, if 
there is a difference in the morbid anatomy of inflammation 
which varies with its seat in particular tissues, and if these dif- 
ferences are always characteristic of the disease in question, why 
should they not modify the treatment accordingly ? Since the 
symptoms, course, and mode of termination of the diseases are 
really so unlike, is there any good reason why an inflammation 
of a serous membrane should be treated as if it were identical 
with an inflammation of the cellular tissue ? I think not. 

I know that it is possible, and that there is a strong temptation 
so to refine and to rarify the symptoms by which diseases are 



456 LECTURES, CLINICAL AND DIDACTIC, 

differentiated as to leave no particular meaning in them, and to 
exclude a more practical idea of disease and its 

Pathological deductions. . 

treatment. But this is the other extreme. We 
must, and will always have, a theory of the disease which we 
undertake to cure. And, good or bad, true or false, that theory 
stands in our minds as a chart of its special pathology. Other 
things equal, the clearer and more correct our views on the sub- 
ject, the fuller will be the measure of our success and usefulness ; 
for the physician who knows as definitely and accurately as possi- 
ble what it is that he wishes to cure, will usually exercise the 
greatest care in the choice of the means which he employs to 
that end. 

Now our clinical knowledge of the nature, peculiarities, com- 
plications, and tendencies of cellulitis enables us, not only to treat 
the symptoms that are present in the earlier stages of the disease, 
but to forecast and avert such as might and would otherwise fol- 
low. When we are called to a patient like either of those of 
whom I have spoken, and whose case is the groundwork of these 
remarks, we must cast about to see if we can not terminate the 
inflammation, or at least avoid some of its more serious con- 
sequences. 

And what are the consequences that we wish, if possible, to 
turn aside ? They are (1) to prevent the exudation of the liquor 

sanguinis, or serum, into the meshes of the 

intra-pelvic areolar tissue ; (2) if it has been 
already poured out, to promote its absorption and removal, and 
(3) to prevent suppuration, or abscess. These general indica- 
tions, therefore, correspond with, and concern the three last stages 
of pelvic cellulitis, viz. : effusion, resolution and suppuration. 

If we consider these enquiries in the order named, you will per- 
haps be able to obtain the best idea of the special therapeutics of 

pelvic cellulitis. It is as reasonable to suppose 

To prevent effusion. . -1-1 p 

that we have remedies which are capable ot 
acting in such a manner upon the congested cellular tissue as to 
prevent effusion therein, as that we have those which are known 
to produce a similar effect in the first stage of serous inflamma- 
tions. There is no reason why, if we begin in season, many cases 
of threatened cellulitis should not be prevented from progressing 
beyond the stage of congestion. We ought to be able to cut short 



ON THE DISEASES OF WOMEN. 457 

this disease as we sometimes do pleurisy, peritonitis, synovitis, 
and pneumonia. 

Of course, if the patient is peculiarly susceptible, and the 
interna/ eondf^ms, as well as the external circumstances, con- 
spire to produce it ; and more than all, if we are not called in 
the incipient stage, or what is equivalent, do not know what dis- 
ease we are prescribing for, the chances are that effusion will not, 
or can not be prevented. But our duty is plain. If there are 
remedies that are capable of removing and relieving the accumu- 
lation and stagnation of red and white corpuscles in the vessels 
of this same connective tissue, and of thus averting the conse- 
quences that might follow, we should be prepared to prescribe 
them intelligently. 

The well-known effects of aconite in allaying the fever, in 
equalizing the circulation, in promoting a critical perspiration, or 
diuresis, and putting an end to threatened local 
inflammation, renders it very useful in this stage 
of the disease. The disease being consecutive to parturition, and 
allied as it is in most cases to surgical fever, the earlier this remedy 
is used the better. My own preference is to give it in the second or 
third decimal attenuation, and, under these particular circumstan- 
ces, to repeat the dose as often as every fifteen or twenty to thirty 
minutes. 

If the patient suffered extremely during labor, if labor was 

very prolonged, or if it was completed by instrumental aid, 

arnica may be used both topically and inter- 

Arnica. . ,.,,.. 

nally. Ihere is no valid objection against alter- 
nating aconite and arnica for the relief of these symptoms. The 
arnica should, however, be given at longer intervals than the 
aconite, and, if you prefer it, in a higher potency. 

Belladonna has a specific relation to cellulitis, especially if it 
is of an erysipelatous type or character. In the outset of 

the attack it may even be preferable to 

Belladonna. . . , . , . , . , 

aconite, providing there is not a veiy high 
degree of fever, and the nervous symptoms predominate. Given 
early and rapidly, it may suffice to avert the inflammation, par- 
ticularly in the case of nervous and delicate women, with arrest 
of the lochia, meteorism of the abdomen, throbbing headache, 
delirium and photophobia. Many experienced and reliable prac- 



458 LECTURES, CLINICAL AND DIDACTIC, 

titioners prescribe aconite and belladonna in alternation for the 
relief of these symptoms, and are of opinion that, thus given, they 
do most excellent service. Whether or not the same prompt and 
desirable results could, in this instance, be obtainM by the reme- 
dies given singly, my experience will not enable me to decide. 
Nor will the experience of any single practitioner settle this ques- 
tion for you. 

There is another remedy which I believe to be of incalculable 

service in the incipient stage of puerperal cellulitis, as indeed it is 

in puerperal peritonitis also. That remedy is 

Veratrum viride. , . 

the veratrum viride. I hose of you who were 
present at the meeting of the Chicago Academy of Medicine, held 
last month (February, 18T2), will remember the excellent report 
of Dr. W. H. Burt, of this city, on the physiological and toxical 
effects of this poison.* Its wonderful power to control and regu- 
late the vascular movements, to equalize the circulation, and, as 
it were, to stamp out a local congestion that would almost inevit- 
ably result in inflammation, is being recognized by physicians of 
all schools. 

My experience, as stated before the Academy during the dis- 
cussion on Dr. Burt's paper, has satisfied me that this remedy 
holds some specific relation to the female generative system. 
Precisely what that relation is, I can not say. But it appears to 
be especially adapted to the relief and removal of puerperal 
inflammation. For many years I have been in the habit of pre 
scribing it whenever, in a lying-in woman, the first symptoms of 
pelvic, or peritoneal congestion show themselves ; and, when my 
directions have been faithfully followed, the result has been 
most happy. It restores the milk and lochia, when these have 
been suddenly suppressed, quiets the nervous perturbation, 
relieves the tympanites and the tenesmus, whether vesical or 
rectal, and frequently cuts short the attack. When called in 
season, I have seldom failed to set aside a threatened cellulitis 
by the same means. My custom is to give it in the second or 
third decimal dilution. In an urgent case, the dose should be 
repeated every twenty minutes or half hour, for four or five times 
successively, and afterwards less frequently. 

You will find the particulars of some very interesting cases of 

* See the U. S. Med. and Surgical Journal, Vol. VII, page 268. 



ON THE DISEASES OF WOMEN. 459 

erysipelas cured by the local and general use of the veratrum 
viride in Prof. Hale's work on Materia Medica.* 

In addition to the faithful employment of one or more of these 
internal remedies, it may serve a good purpose, and can do no 
possible harm, to resort to the local use of dry 
heat by means of hot flannels, or of a dinner 
plate that has been immersed in hot water, wrapped in flannel 
and then placed directly over the seat of the pain. Sometimes 
great good can be effected by applications of towels or cloths 
wrung out of hot water, and frequently repeated. But best of 
all is the simple, old-fashioned bran poultice that I have so fre- 
quently recommended you not to forget in cases of threatened 
puerperal inflammation of whatever variety. 

For the stage of effusion, which in many, and perhaps in a 
majority of cases (as you will be called to them in private prac- 
tice), can not be averted, a Afferent class of 

For the stage of effusion. . . *&. 

remedies are certain to be indicated. Promi- 
nent among them are apis mellifica, arsenicum alb., bryonia, rhus 
toxicodendron, digitalis, cantharis, mercurius sol., stibium, helle- 
borus niger, colchicum and sulphur, which may be given accord- 
ing to the particular symptoms, or group of symptoms that are 
present. 

Concerning the use of the apis mel., which is an invaluable 

remedy at this stage of the complaint, I am of the opinion that 

many physicians have failed with it because 

Apis mel. . . 

the preparation which they have given has not 
been trustworthy. In 1868, my friend, Dr. J. D. Craig, of Niles, 
Mich., sent me a trituration of the remedy which he had prepared 
and prescribed with excellent effect. His method was to extract 
the sting of the honey-bee, and its poison-bag also, with a pair 
of forceps, and then to triturate these with the saccharum lactis 
in the proportion of two grains of the sugar to one sting. This 
he called the first trituration, from which others could be made 
in the usual manner. I haA^e prescribed this preparation in the 
second stage of cellulitis, and in dropsical disease, with good 
effect, and can therefore recommend it to you. 

But, if you desire to facilitate resolution, and to counteract the 

* The Horn. Mat. Medica of the New Remedies, by E. M. Hale, M.D., etc., second 
edition, 1867, P a g e io 53- 



460 LECTURES, CLINICAL AND DIDACTIC, 

tendency to suppuration (which, indications are identical), it is 
indispensable for you to put your patient upon a 
good diet. If the digestion is impaired, and food 
can not be taken, or tolerated, that disorder should be corrected 
as speedily as possible. And, when it is remedied, you must see 
to it that your patient is not starved into the very condition that 
you wish to avoid. For in most cases of this kind, the quantity 
of serum effused, the size of the tumor, and the risk of abscess 
bear a proper relation to the impaired quality of the blood, and 
to the too rapid destruction of tissue that is going on in the sys- 
tem. And, unless the patient's strength is fortified against it, 
you will learn when it is too late, that either a passive, but very 
extensive, infiltration of serum has taken place, or that pus has 
already been formed and is seeking an outlet. 

Under these circumstances, therefore, do not permit the febrile 

condition to mislead you. If such a result were desirable, a rigid 

diet would be the very best means of inducing 

Caution. . 

a hectic lever and its attendant symptoms. I or 
the weaker your patient, the greater the liability to fever and to 
the non-removal of the tumor, excepting through the process of 
suppuration. In puerperal women, especially, whose strength 
has been taxed during gestation, and who have survived the mar- 
tyrdom of labor, there is a strong predisposition to the diathese 
de suppuration of Trousseau. If you persist in keeping them 
upon an insufficient aliment, the best chosen remedies will not 
help you out of the difficulty. Indeed this is one of those condi- 
tions in which good food may be worth more than medicine. 
I firmly believe that the patient who was before you at my last 
lecture, would have died during her first week in the hospital if 
she had not been properly nourished. 

Nor do I know of anything that is more beneficial in some of 
these cases than certain preparations of alcohol. There is no 

danger of exciting inflammation or fever by 

Stimulants. 

the proper use of the best brandy, or whiskey. 
Stimulation will be well borne, and may bridge over the chasm. 
The alcohol acts most beneficially if mixed with some nutrient, as 
for example, with milk, the whites of eggs, or beef tea. Two or 
three table-spoonfuls of milk punch may be given every one to 
four hours, according to circumstances, and continued until the 



ON THE DISEASES OF WOMEN. 461 

crisis has passed. Wine will not suffice. The malt liquors will 
answer a better purpose farther on. 

Certain external means may conduce to the same end. I have 

great confidence in the bran poultice already recommended. It 

may be applied day and night for an indefinite 

Emollients. \ _ ££_ -,.-,. 

period. Where the induration, or rather, the 
tumor is above the brim of the pelvis, an excellent expedient, 
designed to facilitate its resolution, is the local application of the 
camphorated oil, which consists, as you know, of gum camphor 
dissolved in olive oil. The inflamed region should be thoroughly 
anointed with it, and then covered with a thick layer of cotton 
batting. If the pain is very acute, and more especially if it is 
ovarian, one part of the tincture of hamamelis may be added to 
four parts of hot water, and applied topically by means of a com- 
press. If the cellulitis is of traumatic origin, arnica may be used 
in the same way. A blister would de-vitalize the tissues and do 
positive harm, and so also would the tincture of iodine. Abso- 
lute rest is indispensable to the cure. 

The best general rule for the treatment of the suppurative stage 
is to avert it if you can, but to promote the discharge of pus if 

you must. If you find that an abscess really is 

To promote suppuration. . 

iormmg, no matter where the fluctuation may 
first be observed, give the patient hepar sulphuris, calcarea carb., 
mercurius sol., sulphur, or such other remedies as the symptoms 
may require. Or, if the discharge has already been too copious 
and long continued, silicea may be prescribed with a view to its 
arrest. 

Emollients of linseed meal, slippery elm, or bread and milk, 
hot fomentations and the hip-bath will sometimes afford relief to 
the pain and hasten the formation and discharge of pus. Or you 
may apply warm water per vaginam by means of a syphon, so as 
to facilitate the same process internally. 

If the abscess points externally (and it is most desirable that it 

should do so), it may and should be lanced so soon as it is ready 

to discharge. Wait until the integument cov- 

How to open the abscess. . 

ermg the tumor has softened and become thin ; 
and be careful to make the puncture as low down as possible in 
order not to open the cavity of the peritoneum. It is safest to cut 
close to Poupart's ligament, more especially from the middle por- 



462 LECTURES, CLINICAL AND DIDACTIC, 

tion of that ligament outwards, in order to shun the sheath of the 
femoral vessels. Some authorities recommend to make a valvular 
incision in opening these abscesses, in order to avoid the possible 
introduction of air into the abdominal cavity. 

Unless there is a very decided fluctuation of the tumor along 
some portion of the vaginal wall or roof, or you are positive con- 
cerning the presence of pus therein — from having brought it 
away with the exploring needle — you will not be warranted in 
opening it per vaginam. For there is danger in such a case of 
wounding some of the pelvic viscera. But when there is a point 
of fluctuation, you may puncture very carefully and evacuate it as 
you would if it were a more accessible hsematoma. It is safer, as 
in hematocele, to lance such an abscess through the vaginal sep- 
tum, than from the rectal side of the tumor, because of the 
greater number of small vessels that are supplied to the latter. 
Whenever it is possible the sac should be entirely emptied, else a 
fistula may form and remain. 

After the abscess has been evacuated, it may be poulticed again 
for a short time, and then dressed with a lotion 
of calendula, or of a weak solution of car- 
bolic acid in water. If fistulas have formed, either of these mixt- 
ures may be injected into them. 

Mrs. S. is now taking of apis mellifica 3, a dose every three 
hours. The camphorated oil is still being applied locally, and she 
has the best diet the hospital affords. 

VAGINISMUS. 

Case. — Mrs. N , twenty-three years of age, married, has 

been out of health from the time her menses made their appear- 
ance, which was while she was at school, in her fourteenth year. 
She had all the usual symptoms of neuralgic or spasmodic dys- 
menorrhcea with each monthly return. The flow, after the first 
day, was quite free, and it usually continued about a week. She 
was married at eighteen, five years ago. Soon after this the dys- 
menorrhcea ceased, and the "period" has been quite easy and 
natural until now. She has never borne any children, nor ever 
had a miscarriage. She menstruated as usual last week. A slight 
and temporary leucorrhcea sometimes succeeds the catamenial 
flow. 

She complains of great fatigue on slight exertion. This is 






OX THE DISEASES OF WOMEN. 463 

especially marked at intervals, which intervals have no known 
relation to the monthly cycle. At other times she is as active 
and vigorous, and can walk or ride as far as any one almost. 
There is a good deal of pain and soreness along the superior por- 
tion of the spinal column, extending from the upper cervical to 
the last dorsal vertebra. Sitting, standing, and writing increase 
this pain and aching, which do not appear to be influenced by 
exposure to changes of weather. Sometimes she says there is a 
burning sensation along this portion of the spine, and again the 
burning is referred to the region of the left ovary. Occasionally 
the pain leaves the back and goes to that ovary. While it re- 
mains there, the left iliac region becomes tender to the touch, 
and she involuntarily retracts, or flexes the thigh upon the abdo- 
men. 

Her chief complaint is of pain and extreme tenderness at the 
ostium vaginae. This orifice is so sensitive, and the slightest con- 
tact is so very painful, as to render marital intercourse almost 
impossible. For more than four years she has consented to it 
only a very few times, and then has suffered an indescribable 
martyrdom. 

Physical examination finds the parts quite normal, excepting 
that just within the vaginal orifice, there is great tenderness to 
the touch, and the moment that the finger comes into contact 
with the marginal remains of the hymen, there is an immediate 
spasm of the muscular coat of the vagina, which causes extreme 
narrowness of that canal, and prevents its admission without con- 
siderable force. The superior portion of the vagina is flaccid and 
capacious enough. The uterus is in its proper place, and does 
not appear to be changed in any respect. The bladder and the 
rectum are healthy. 

This complaint is a very painful one, and one from which 
women sometimes suffer in silence for years together without the 
courage to consult a physician for its relief. I believe that, in its 
milder forms, it is more frequent than is generally supposed. It 
may occur in the virgin, or in the case of those who are married, 
but not in those who have ever had a child or children. 

The symptoms are similar to those which our patient has de- 
tailed. There is almost always spinal tenderness, soreness, and 
lameness, which are generally located between 
the shoulders and along the cervical portion of 
the spine. Sometimes, however, it is lower down the spinal 
column, and is described as a weakness of the back and hips. 
The soreness or weakness is paroxysmal, and is aggravated by 



464 LECTURES, CLINICAL AND DIDACTIC, 

exercise, but more especially by sexual excitement. In its recur- 
rence it is very apt to alternate with ovarian pain, burning and 
irritation. A hysterical cough, aphonia, headache, or a tendency 
to general spasms, are not unfrequent accompaniments of this 
spinal irritation. Spasmodic dysmenorrhea and strangury often 
complicate the case, and cause additional suffering. (Exit the 
'patient.") 

But the peculiar and distinctive symptom of vaginismus is the 

hyperesthesia of the vulva and of the outer extremity of the 

vagina, which is so very sensitive that even the 

Local hyperesthesia. _ . 

slightest touch causes a spasm ot the sphincter 
vaginae, and a closure of that canal. The closure may also extend 
to the sphincter ani. The location and extent of this sensitive sur- 
face varies in different subjects. In virgins, it may be limited to 
the outer face of the hymen, which membrane, in these cases, is 
thicker and more firmly organized than usual. In those married 
women in whom the hymen has been ruptured, the tenderness is 
frequently most marked somewhere along the marginal remains 
and attachments of this membrane. The carunculse myrtiformes 
may be exquisitely sensitive. In many cases the most tender 
point is upon the side of, or near to the meatus urinarius. In 
others, it is about the orifice of the vulvo-vaginal gland, and 
sometimes at the fourchette. 

In this condition the contact of the finger, or even of a camel's 
hair brush, or of a feather, may cause the greatest agony, and 
perhaps throw the patient into convulsions. Coitus is impossible, 
and you can not introduce the smallest speculum without almost 
killing her ; indeed, in some cases that I have treated, the vaginal 
orifice was so closely and tightly constricted that I could not pass 
my little finger, or even a female catheter, into the vagina with- 
out exercising undue force. The sexual act being more or less 
completely performed, the suffering finally becomes so great that 
the parties are forced to desist, and most of these patients con- 
fess either that they have altogether relinquished the attempt and 
concluded to live apart, or, as they sometimes do, as brother and 
sister ; or that it is undertaken only at long intervals. Usually 
such women remain childless. It has happened, however, that 
even under these embarrassing circumstances, conception has 



Causes. 



ON THE DISEASES OF WOMEN. 465 

taken place, and gestation and parturition have cured the case 
spontaneously. 

If these symptoms continue for years, and the patient is sub- 
jected to all the mental worry that is their indirect consequence, 
and to the contingent diseases which such a 
state of the nervous system is almost certain to 
induce, her general health will finally become impaired, and she 
will pass into a state of decline. She will become prematurely 
old, emaciated, dyspeptic, hypochondriacal, and a wretched " ner- 
vous wreck." The worst results may happen to her household 
and family. She is very apt to conclude, and may even be told 
by her physician, that she has an incurable disease of the womb. 
Her husband is likely to become estranged, and her married life 
to prove a disastrous failure. 

This disease is frequently complicated, either as cause or effect, 
with spasmodic dysmenorrhea. Sometimes it arises from a pru- 
ritus of the vulva, which is due to vulvar eruptions. Or it may 
be caused by caruncles of the meatus urinarius, vulvar follicu- 
litis, vesical, urethral or rectal tenesmus, haemorrhoids, fissures of 
the anus, or of the vulva, vaginitis, uterine displacements, an irri- 
table uterus, nodular neuromata of the vagina or vulva, or by the 
contact of acrid discharges in utero-vaginal leucorrhcea. 

The most cultivated and gifted women, those of a high moral 
or emotional nature, are most subject to this affection. This is 
especially true of such of them as inherit the hysterical disposi- 
tion, and who are liable to the different forms of spinal irritation. 
All this large class of women are exceedingly prone to be mis- 
mated, and to suffer from personal antagonisms which jar their sensi- 
bilities and derange the sexual sphere. Thus it may happen that 
a delicate, sensitive, impressible woman, who, if she were properly 
mated, would be exceedingly happy and contented, is tied to one 
whose brutal approaches become more and more loathsome and 
repulsive, until finally this morbid sensibility which ruins her 
health and happiness is developed. I have seen one case of the 
kind which really was more painful to witness than anything 
beside that has ever occurred in my professional experience. 
There are no toxical influences which are so difficult to antidote 
as those which arise from sexual incompatibility. 

You need have no difficulty in establishing the diagnosis. First 
30 



466 LECTURES, CLINICAL AND DIDACTIC, 

examine the patient by means of the " touch/' If she is extremely 
nervous and apprehensive, shakes like one in a 
fit of ague, and is almost or quite convulsed 
the moment the vulva is touched ; if there is a manifest spasm of 
the sphincter and the constrictor muscles of the vagina, so that 
the finger cannot pass into the canal without causing her more or 
less agony, you had better desist, and proceed to put her under 
the influence of an anaesthetic. A few whiffs of ether, or of 
chloroform, will quiet her apprehension, overcome her opposition, 
allay the super-sensitiveness of the vulvar mucous membrane, and 
more than all relax the spasm so that the finger, or speculum, 
will enter quite readily. 

Dr. Sims has given us the differential points in vaginismus in 
one of his laconic sentences: " The supersensitiveness is diagnos- 
tic ; the spasm pathognomonic."* 

The prognosis is generally conceded to be favorable. If, how- 
ever, the disease is the result of a profound lesion of the nervous 
centers, as sometimes, although very rarely, happens, it is not 
likely to be radically cured. Something depends also upon the dura- 
tion of the disease and the serious inroads it has made upon the 
general health. But, in almost every case of vaginismus, you 
will expect to cure your patient, providing your instructions are 
carried out, and she has the patience to wait for the result. 

Treatment. — The treatment is both medical and surgical. The 

remedies most frequently indicated are those which are suited to 

the relief and cure of the intercurrent disorders, 

Medical treatment. . . 

more especially 01 menstruation, innervation, 
and digestion, and to the pain and suffering in the bladder, the 
urethra and the rectum. These should be carefully chosen and 
affiliated. I am not aware that any of them hold an especial 
curative relation to the vaginismus separately considered ; nor is 
there on record a well authenticated cure of this disease by the 
use of internal remedies alone. Belladonna, atropine, thuja^ 
macrotin, sepia, cocculus, conium, platina, nux vomica, pulsatilla, 
hvoscyamus, ignatia, and mercurius, include those which are more 
likely to be indicated than any others. If necessary, (and it often 
is,) either of them can be given in conjunction with the surgical 
treatment. 

*Clinical Notes on Uterine Surgery, by J. Marion Sims, M.D., etc., etc. New- 
York, 1866, p. 320. 



ON THE DISEASES OF WOMEN. 467 

As usual in gynecological questions, authorities are divided on 
the question of employing the knife for the radical cure of vagi- 
nismus. My own opinion, based upon the suc- 
cessful treatment of numerous cases, is that, 
unless there is some especial reason why the cure should be speedy, 
it is best to try the milder means first. This is especially true of 
cases which are not very severe. 

One of the means designed to overcome this disposition to spasm 

of the vaginal muscular fibre is the dilatation of the canal, or 

rather of its constricted portion, by graduated 

Dilatation. . - . 

bougies. An ordinary rectal bougie may be cut 
in two, and one half anointed with simple cerate, glycerine, olive 
oil, or with an ointment consisting of the extract of belladonna, 
one part, and lard or simple cerate, six parts. This may be very 
carefully introduced and allowed to remain, according to circum- 
stances, for a period varying from a few minutes to an hour or 
more, when it should be withdrawn. Of course the patient should 
keep the horizontal posture meanwhile. You may be obliged to 
commence with a very small instrument of this kind, but gradu- 
ally the larger ones can be used, and their presence will be toler- 
ated so that they will no longer occasion pain. The patient can 
soon be taught to introduce and to remove them herself. After a 
time, with proper diet, remedies and regulation of the habits in 
every respect, you will find that it is possible to pass the largest 
size of the rectal bougie without suffering, and that the case is 
practically cured. The complete interdiction of coitus while 
this dilatation is being effected, is a condition of the cure. 

Case. — March, 1862, Mrs. consulted with me for the 

relief of an irritable and sensitive condition of the vagina which, 
during her three years of married life, had caused her untold suf- 
fering, and interfered most positively with sexual congress. She 
was a most intelligent person, frank and candid in her manner, 
and extremely anxious that something should be done for her 
relief, more especially lest her husband should become disaffected, 
and her family and friends continue to ridicule her for never hav- 
ing become a mother. 

On physical examination there was nothing abnormal about the 
external generative organs, except the hyperesthesia of the vulva 
and of the vaginal outlet. The slightest and most delicate touch 
with the finger caused the vaginal spasm immediately, and she 



468 LECTURES, CLINICAL AND DIDACTIC, 

was thrown into the same state of suffering which she said she had 
always experienced in the conjugal act. Iplacedher under the influ- 
ence of sulphuric ether by inhalation, and these symptoms disap- 
peared. The dilatation with bougies anointed with the bella- 
donna and simple cerate, was begun and continued every two days 
for a fortnight, then every day for another week, and the barrier 
to intercourse was removed. She soon conceived, and now has a 
son, a beautiful boy, nine years old. I gave her no medicine. 

In most cases to which this plan of dilatation is equally well 
adapted, the cure will not be so speedily effected. It generally 
requires about two months, sometimes a little more, and some- 
times less, to accomplish the desired result. If you prefer, you 
can make use of a series of conical glass dilators, such as I hold 
in my hand, instead of the bougies. These were invented by Dr. 
Sims, and answer a very good purpose. The warm bath and 
electricity are useful auxiliaries to this treatment, in which I have 
gr*eat confidence. Scanzoni treated one hundred cases of vaginis- 
mus by a very similar plan and cured them all without recourse 
to the knife. 

A very few cases are reported to have been cured by excision 

of the irritable tumor which is sometimes found at the mouth of 

the urethra. Others have been remedied b} r 

Excision of irritable tumors. . 

the removal of the vaginal neuromata, the cure 
of vaginitis, fissures of the parts, and such diseases as could be 
more easily reached and removed by local and general treatment. 
Dr. Tilt recommends to effect the forcible dilatation of the con- 
strictor muscles of the vagina in the same manner as your pro- 
fessor of surgery, only a few days since, over- 

Dr. Tilt's operation. X \ 

came a spasm of the sphincter ani in a patient 
which he had before you. Having anesthetized the woman, he 
introduces both of his thumbs with their backs toward each other, 
into the vaginal orifice, and then stretches it firmly and forcibly 
for the space of five or six minutes. After this a plug, or dilator, 
is introduced and kept in position for several days by a T bandage. 
This mode of treatment, however, is not applicable, while there is 
any coincident or remaining uterine or vaginal disease. 

Dr. Sims practices deep incisions on the right and left side of 
the mesial line of the vagina posteriorly. The patient should be 
placed upon the back, and brought thoroughly under the influence 



ON THE DISEASES OF WOMEN. 469 

of ether or chloroform. With a pair of curved scissors remove the 
remains of the hymen. In order to separate 

Dr. Sims' operation 

the labia laterally, to open the canal as wide 
as possible, and to draw the fourchette very tense, the index and 
middle fingers of the left hand are to be passed into the vagina. 
Then with a common scalpel you make an incision through the 
vaginal tissue, a little to the right side, bringing it from above 
downwards, to the raphe of the perineum, thus making one side 
of a Y ; then insert the knife on the left side and cut obliquely 
toward the other incision, so as to join it at the raphe. Follow 
along through the raphe itself until the cut is Y shaped. Thus 
the incision will pass across the sphincter vagina for about half an 
inch, but not through it, and, in all will be nearly two inches in 
length, varying in different subjects according to the development 
of tissue in each. 

If there is considerable haemorrhage, pressure, the local appli- 
cation of ice or of the per-sulphate of iron will arrest it. If the 
flow of blood is free, but not excessive, the dilator may be intro- 
duced immediately, and the pressure which it exerts will serve to 
arrest it. Usually the dilator is not applied until twenty-four 
hours after the operation, when it is kept in situ by an appropriate 
bandage, after which it is worn "for two hours in the morning 
and two or three hours in the evening, according to the tolerance 
of the patient." Dr. Sims says : " I have been often astonished 
at the rapidity with which the cuts heal, the process being seem- 
ingly facilitated by the pressure of the glass dilator, which is to 
be worn daily for two or three hours, or until the parts being 
entirely cured, and all sensitiveness removed, the patient may be 
pronounced competent to fulfil comfortably and pleasantly the 
duty of a wife."* 

In brief, therefore, Sims' operation is preferred to that of 
Burns', which consisted in dividing the pudic nerve. Some very 
interesting cases cured by Sims' method have been reported by Drs. 
H. B. Clarke, T. G. Comstock, W. Tod Helmuth and others. 
You will find a suggestive report on this subject by one of our 
former pupils, Dr. W. A. Burr, of Nebraska, in the current issue 
of the United States Medical and Surgical Journal. f 

*Bulletin of the N. Y. Academy of Medicine, vol. I, p. 434. 
fVolume VII, page 367. 



470 LECTURES, CLIXICAL AND DIDACTIC, 

In some of my cases, where the remains of the hymen have 

constituted the focal point of the hypersesthesia, I have removed 

them with a curved scissors and then finished 

Another expedient. 

the cure by means ot dilatation and without 
any incision. This treatment will be followed in the case which 
you saw a few moments ago. 

Attacks of vaginismus that are incidental and transient in their 
duration may be relieved by a more simple but equally useful 

expedient. A mixture consisting of chloroform, 

Local anaesthesia. it «-i -i i 

one drachm, and olive oil and glycerine, each 
one ounce, may be applied by means of a cotton tampon, provid- 
ing the spasm of the vagina does not prevent its introduction into 
that canal. In that case it may be thrown into the rectum, when 
the spasm will very soon cease. Afterwards the proper medical 
and hygienic treatment can be resorted to for the radical cure of 
the conditions, or diseases, upon which these paroxysms are con- 
tingent. 

PHYSOMETRA. 



Case. — May, 1864. Mrs. B , aged twenty-four, of sanguineo- 

nervous temperament, has been married six years, and is the 
mother of two children. She was delivered of the youngest of 
these one year ago, — during the riots in the city of New York. 
She says she had a short and easy labor, after which she did well 
until the third day, when, the report having been circulated that 
the house in which she was living would be fired or destroyed, 
she was obliged to remove to another. The distance being only 
two squares, she insisted upon walking, and really accomplished 
the task, but under great mental excitement. The result was at 
first a partial, and, after the fifth day, a complete suppression of 
the lochia. 

In a short time her present symptoms began to trouble her, and 
they have continued during the whole year. There is a circum- 
scribed enlargement of the abdomen, situated in the mesian line, 
and extending from the pubis towards the umbilicus. This tumor 
increases in size so that at times she is quite as large, and looks as 
if she were seven months advanced in pregnancy. At other times, 
and especially after a good night's rest, its size is greatly reduced. 
Exercise and excitement increase its volume. 

When she reclines the tumor gravitates or rolls toward the side 
upon which she is lying, but without any change in its form, and 



ON THE DISEASES OF WOMEN. 471 

without borbor}*gmus. It is still circumscribed, and always tym- 
panitic. The neighboring parts yield their normal sounds on per- 
cussion. The only pain she has had is a species of soreness from 
outward pressure, or distension. She is at times sensible of hav- 
ing had a discharge of flatus per vaginam, but has never had 
eructations. 

Sometimes, she says, this tumor or swelling feels as if it were 
rising into the stomach, and again into the throat. Occasionally 
she has headache and a flushed face, especially in the afternoon. 
She is a very intelligent woman, and is confident that she has 
never before had any uterine difficulties. The urinary function 
is normal, and in every other respect she is healthy. She was 
unable to nurse her child. 

It may be a long time before you will see so good an illustra- 
tion of this curious affection as we have here this morning. 
Indeed, owing to its rarity, many physicians of 

The tumor. . _ . 

large experience have never seen a case ol this 
kind. If you observe the physical characters of this phantom 
tumor, you will note that its outline is as well-defined as that of 
an ovarian cyst. It may be very hard, or it may yield to pressure, 
like a soft foot-ball, and is tympanitic on percussion. You hear 
this sound distinctly. The tumor changes its position when she 
turns upon either side, and rolls about to a limited degree, but 
there is no bulging in the lumbar region, and no flattening of the 
anterior surface of the tumor when she lies upon her back, as in 
ascites. 

Physometra, or the collection of flatus in the womb, is almost 
always, directly or indirectly, related to gestation, or to the par- 
turient state. Sometimes, however, it occurs during menstrua- 
tion, and again in consequence of the presence of uterine hyda- 
tids, moles, polypi, and such intra-uterine growths as are liable to 
become decomposed, either before or after their detachment. 
Whether as cause or effect, hysterical symptoms are always pres- 
ent in these cases, as in other forms of tympanites to which women 
are more especially, but not exclusively liable. The lochia, the 
milk, and the menses, are suppressed. Sometimes, however, the 
breasts fill as they do in pregnancy. The nervous symptoms 
predominate. 

The most commonly accepted cause of this singular infirmity is 
the retention and decomposition in utero of the foetus, of some 



472 LECTUKES, CLINICAL AND DIDACTIC, 

portion of the secundines after delivery ; or similar changes in 
fragments of intra-uterine growths which have 
failed to be expelled by nature, or removed 
by the physician. The gas that is formed in consequence of 
the decomposition of organic matters is fetid, 
reSfneT P ° sition ° f ma " er and - is incarcerated in the cavity of the womb 
by the spasmodic closure of the cervical outlet. 
It is possible that similar changes may take place in the men- 
strual excretion, and also in the membrane (decidua menstrualis), 
which is sometimes exfoliated during that process, and which if it 
is retained by closure of the uterine neck, might also undergo 
chemical decomposition. Occasionally the arrest of the lochia 
results in the development of this form of uterine tumor. This 
cause is more powerful when conjoined, as in this case, with 
apprehension and anxiety, as well as with premature exposure and 
excess of fatigue almost immediately after the birth of the child. 
Some writers ascribe the uterine enlargement in physometra to 
a collection of atmospheric air in the womb, which is either drawn 
into that organ by a species of suction, or passes 
^suction of air into the [ n ^ ft wnen the os uteri is open and other mat- 
ters have so escaped as to leave a vacuum, into 
which the air may rush until it is filled. Dr. Harley cites a case 
of alternate admission into, and expulsion of air from the vagina.* 
Something of this kind, it is thought, may, in very exceptional 
cases, take place in the womb. 

But there are instances in which, unless we ascribe it to mental 

excitement, it is quite impossible to detect any cause for this 

tumor. Acting upon a hysterical preclisposi- 

Mental causes. . . , . , J r " L p 

tion, there is no valid reason why an excess of 
flatus might not be as readily secreted or formed within the ute- 
rus, as it obviously may in the bowel or the stomach from a simi- 
lar cause. And nothing is more common than hysterical tympan- 
ites from emotional causes in this class of patients. But I will 
not detain you with further remarks on this subject. 

The diagnosis is much easier than it was a few years ago. You 
have only to put the patient under the influ- 
ence of chloroform or ether, and the differenti- 
ation of this species of tumor will declare itself. For if it is a case 

^Transactions of the Obstetrical Society of London, Vol. IV., page 173. 



ON THE DISEASES OF WOMEN". 473 

of physometra, or indeed of a phantom tnmor of any kind, the 
enlargement will disappear altogether. You can satisfy yourselves 
that the accumulation has been in the womb and not in the 
bowel, by passing a small canula, or a male catheter, through the 
os uteri. Then, by placing the outer extremity of the instru- 
ment under water you can evacuate the tumor through it, and be 
assured of the escape of gas therefrom. I tried this experiment 
on our patient yesterday, and, therefore, am confident in my 
diagnosis. 

The treatment consists in removing any decayed substances that 
may have remained in utero ; and in preventing their retention in 
the future. The cervix may be kept open for 
the free discharge of such matters, and of the 
gas also, by the use of the sponge -tent and the ordinary means 
of dilatation. If the case is a recent one, and the lochia have been 
suppressed, they should, if possible, be restored. If the patient 
is hysterical, this tendency should be counteracted by appropriate 
medical, moral and hygienic means. If the excessive size of the 
tumor worries her, it may be evacuated a few times for her com- 
fort. Mrs. B. will take a dose of belladonnas every four hours 
during the day.* 

*In four weeks this woman was well and menstruating normally. 



474 LECTURES, CLINICAL AND DIDACTIC, 



LECTURE XXVIII. 

amenorkhcea, with prolapses uteei and obstinate vomiting. 

Gentlemen : 

I doubt if it would be possible to occupy the first part of this 
hour more profitably than in the clinical review of a case from my 
private practice. It interested me greatly, and may contain some- 
thing of value to you. It was a case of amenorrhcea, with pro- 
lapsus uteri and obstinate vomiting. The patient did me the 
favor to write out her symptoms in detail. 

Case. — I am 22 years of age, and married ; have been ill with 
an intractable gastric difficulty at intervals for six years. This 
affection first manifested itself after a severe attack of diarrhoea, 
which was followed by spitting up of the food while it was parti- 
ally digested, or still unchanged. This symptom used especially 
to trouble me in the evening, after supper, but sometimes fol- 
lowed the other meals also. Coffee, pastry, and all rich food, 
new vegetables, and many kinds of fruit, were the first articles to 
be rejected by my stomach. Consequently, my diet was reduced 
to meat and bread. For a time all kinds of fresh meat were well 
borne, but finally beef-steak was the only one that would be tol- 
erated. 

The first attack of this indigestion came on late in the summer 
and continued for several months. It returned the next year at 
the same season, and lasted until the middle of the following 
winter, being accompanied by three months of suppressed men- 
struation. These combined troubles occasioned severe headache, 
and bloating of the stomach and the abdomen. However, I rap- 
idly gained in flesh, which was soon lost when the menses 
returned. The next season I derived much benefit from a resi- 
dence of nine months in Saratoga. After drinking its waters I 
returned home with my disease apparently cured. Two years of 
comparative health followed, with occasional symptoms of the old 
trouble, which were generally relieved by the regulation of my 
diet. 

The third attack was preceded, accompanied and followed by 






OX THE DISEASES OF WOMEN. 475 

bilious fever and dysentery, with which diseases I was very ill for 
several weeks. The gastric difficulty did not leave as usual in 
the winter season. The symptoms continued for more than a 
year, the nausea and vomiting increased in frequency and vio- 
lence, and were accompanied by great acridity of the matters 
ejected, distress and burning. I could compare the feeling which 
predominated to no sensation except to that which would be pro- 
duced by many pieces of apple-core moving about in the stomach. 
Constipation and bloating of the abdomen were constant symptoms. 
Medicine seemed powerless ; one article of diet after another was 
abandoned ; my strength gradually decreased ; I became nervous ; 
my nights were wakeful, with unpleasant dreams-, and a dumb 
ague at last set in. Meat and other solid food could not be toler- 
ated by my stomach, and soon the entire system yielded to utter 
prostration and debility. 

The region of the stomach now became very hard to the feel, 
but extremely sensitive to the touch. For seven months menstru- 
ation was entirely suspended. From September to the middle of 
December, I became weaker and weaker. I then began gradually 
to improve, but the vomiting continued nearly every day for 
about four months longer. For six months I had eaten no solid 
food whatever, but had subsisted on porridge and farina. For two 
months I lived exclusively on milk, and a weak strained broth. 

The first discharge of matter or pus by vomiting took place in 
September, and from that time on I continued to raise it. In 
November this matter became more copious, and was thrown up 
as often as every hour in the day. The most abundant of these 
discharges of pus were preceded by sinking spells, with difficulty 
of breathing and numbness. Beside this matter there was also 
vomited a clear fluid which made the throat, mouth and lips burn 
and smart severely. But a thick froth resembling the beaten 
white of an egg^ generally accompanied the pus. 

Intense nervousness, wakeful and often sleepless nights, and 
severe pains in the head, and also in the back and hips, racked 
my delicate constitution terribly. For six months, with but a few 
exceptional days, the vomiting spells followed each other every 
one to six hours. I was entirely confined to my bed for four 
months. 

This was the condition in which I found this patient on my first 
visit. She was a bride of a few months. Her husband and family 
were extremely solicitous concerning her, for, excepting that at 
times she had a rosy English complexion, she really appeared like 
one who could not live very long. Further examination of the 
case from time to time, as she could bear it and as opportunity 
offered, elicited the following additional symptoms : 



476 LECTURES, CLINICAL AND DIDACTIC, 

A large portion of the time, during which, she suffered from 
these attacks of vomiting, the appetite was craving and almost 
ravenous. This was accompanied by extreme depression of 
spirits. For several months after the vomiting came to be of 
almost daily occurrence, there was little or no loss of flesh, the 
cheeks were red and the eyes bright as in perfect health, but the 
complexion had a peculiar bluish hue, especially in the morning. 
The feet and hands, which at other times were almost as cold and 
colorless as marble, became hot and burning. The perspiration 
had a strong, disagreeable odor. This odor was especially bad 
when the vomiting of pus was most frequent and copious. For 
many weeks the stomach was so sensitive that she could tell the 
moment the food entered it, and in what part of the organ it was 
lying. A marked and peculiar feeling for months prior to her 
illness was that of a sharp distress (the "apple-core" sensation) 
just at the entrance to the stomach. This was accompanied by a 
feeling of faintness from lack of food, which eating only increased. 

Each of these attacks was characterized by a more or less pro- 
longed arrest of the menses. She also complained of weakness 
and lameness in the small of her back and hips, with dragging 
down sensations, occasional dysuria and obstinate constipation. 

My first impression of the pathology of this case was, that it was 
one of perforating ulcer of the stomach, and, as you may suppose, 
my prognostications were very cautiously given, 
prolapsus the exciting My second visit disclosed the menstrual com- 
plication, and the third interview decided me 
to request an examination per vaginam. It was accordingly made. 
I found the vulva in a state of hyperesthesia, with considerable 
constriction of the vaginal orifice. The uterus was prolapsed 
upon the floor of the pelvis, and exquisitely tender to the touch. 
After a little delicate manipulation this organ was lifted as far 
toward the superior strait as possible, and the patient directed to 
lie for the most part upon the left side. 1 prescribed nux vom- 
ica 3 , a dose to be taken every three hours. 

The next morning her pelvic and sacral pains had vanished, 
the headache was relieved, the vomiting had been less frequent, 
and she was hopeful. In brief, she kept to her 
wo E nfb. ct ° f repladng the bed for about three weeks more, on account of 
the prolapsus, and also of the menstrual flow, 
which returned within a fortnight. Once in four or five days the 
womb was restored, in case it had fallen, with the index finger. 
Calcarea carbonica 3 was the only remedy that she took after the 



ON THE DISEASES OF WOMEN. 477 

first few days, excepting caulophyllin and coffea, which were 
given incidentally to promote rest and sleep. Menstruation soon 

became regular and normal in every respect. 

The gastric difficulty lessened until almost any 
kind of food could be taken, relished and retained. Her " dumb 
ague" disappeared, and her old flow of spirits returned. In a few 
weeks her health was perfectly restored. In six months she 
became pregnant, and now she has a bright, healthy child, which 
is about a year old. She passed through gestation without any 
morning sickness or vomiting ; and through labor and lactation 
with no untoward or unusual symptoms. Two years have elapsed 
and there has been no return of her disease. 

My object in reporting this case is not to reflect upon either of 
the physicians who preceded me in its management, but to make 

a few practical points that will be available to 

you bye and bye as practitioners. The first of 
these is that your skill in diagnosis, and your success in treatment 
will depend upon the thoroughness with which you examine and 
analyze the case in hand. Much has been said of the importance 
of the "totality of the symptoms" as the basis of treatment. In 

a knotty, complicated case like this, the " total- 
^ Totality of the symp- ity of the symptoms » i nc l uc Les a great deal. It 

classifies and arranges the gastric, the alimen- 
tary and the nervous symptoms as the more prominent and sug- 
gestive; but it is found that those physicians who claim to pre- 
scribe in accordance therewith are very apt to overlook the 
menstrual and uterine complications, or, at least, they do not 
always give them their due prominence. And this fact explains 
some of their failures. For if we should place undue stress upon 
the character of the matters ejected, or the frequency and other 
peculiarities of the vomiting, as interpreting the nature of the 
disease, and as indicative of the remedy, which is characteristic 
and most appropriate for its relief — the result would be that our 
pathology would be at fault, and our therapeutical progress would 
take the wrong direction. 

In a case of this kind it is sometimes very difficult, and even 

impossible to decide which class of symptoms 

The cardinal symptoms. . .. . ~ T( , , 

is really the most significant. If our judgment 
concerning them is based upon their objective consequences, and 



478 LECTURES, CLINICAL AND DIDACTIC, 

not upon their subjective cause and relation, we shall be very 
apt to declare in favor of the former. Hence, it frequently 
happens that the most clamorous signs get the credit of being 
characteristic and sufficient when, in fact, they are not so. 

This is a case in point. The uterus was badly prolapsed, and 

evidently had been each time that she had suffered from the 

gastric derangement The cause of her illness 

Practical deductions. . 

was mechanical and, while it acted, was con- 
stant in its operation. The reflex functional disorder of the 
stomach was so severe and long-continued that it finally developed 
into an undoubted ulceration of that organ. But even when the 
symptoms connected with that ulceration were at their worst, 
there was nothing distinctive in them either as to the cause of 
the difficulty, or the best mode of curing it. 

The second proposition is that while we are careful not to 
exclude some of the symptoms arbitrarily, or through neglect, we 

should not exalt others to an unmerited pro- 
properVymptoms^ 1 ^ 1 to minence indiscriminately, and without good 

reason. The uterine deviation and the men- 
strual arrest were the cardinal peculiarities of the case under 
review. When they were relieved the more remote gastric symp- 
toms disappeared. Now it would not be safe to conclude and to 
insist from this that pessaries and emmenagogues are the best 

means of cure in a case of ulceration of the 
influences pr ° per dinical stomach with similar vomiting ; neither to 

declare that these symptoms are invariably 
due to the same, or to any remote cause, whether sexual or other- 
wise. It is the inference we deduce, and the lesson we learn 
from such an experience that interests the profession, and our 
patients also. It is the physician's tact in taking hold of the right 
thread that enables him to unravel the tangled skein of disease. 

And whoever, in a case of utero-gastric disease, can tell which 
is the primary lesion, and which is the secondary one ; which 

symptoms are first in importance, and which 

Key to success. " pi 

are not ; will have a key to the choice ot the 
treatment proper to these compound cases which he could not 
otherwise obtain. Starting from this point, he may select the 
remedy or remedies, surgical or medical, by a reference to his 
experience, to his library, to his materia medica, or through a 



ON THE DISEASES OF WOMEN. 479 

species of " unconscious cerebration ;" but he will gain his object 
more speedily, safety and surely than if he took a less compre- 
hensive view of the case, and always persisted in beginning at 
the other end of the series. 

You will readily understand how the extreme and persistent 

irritability of the stomach, in a case of this kind, might finally 

involve the most serious consequences. When 

in effects of excessive a j]_ t i ie f ooc [ tnat j s swa llowed is reiected, and 

vomiting. J ' 

the vomiting is so nearly constant, it is impos- 
sible for the patient to be properly nourished thereby. Her 
assimilative functions are sure to be impaired. The digestion, 
the circulation, respiration and innervation cannot escape. And 
thus the general health will be undermined. Organic disease will 
be the indirect consequence, and prostration, debility and death 
may follow. 

Indeed the diseases of any portion of the gastro-alimentary 
mucous membrane are more serious when complicated with uter- 
ine and menstrual disorders than when they 
serious nature of utero- ^ not C0 -exist. For this reason, in women, 

gastro-ahmentary disorders. ' " 

the worst cases of intestinal derangement, and 
indigestion, constipation and diarrhoea are those which are com- 
plicated with intra-pelvic difficulties of various kinds, as for 
example, uterine displacements, ulceration, chronic cervicitis, 
ovaritis, menstrual retention, leucorrhcea, and menorrhagia. The 
remoteness of these several lesions, — which complicate even 
when they have not caused the alimentary disorder, and the 
absence of any very prominent signs of uterine or ovarian 
trouble, may lead to their being overlooked as prime factors in 
the case. If we add to this that a proper physical examination of 
the pelvic organs is usually the last thing to be thought of under 
these circumstances, you will see how it is possible for such com- 
plicated diseases to resist treatment, and finally terminate fatally. 
These cases vary so much, and are so unlike, that one descrip- 
tion will not ansAver for them all ; nor will one kind of treatment 
cure them indiscriminately. Whatever the nature of the indirect 
cause, its effect should be counteracted by its removal. Possibly 
not one in a hundred cases of chronic and persistent vomiting 
may depend so directly as this upon uterine displacement. But 



480 LECTURES, CLINICAL AND DIDACTIC, 

the fact that it may happen should not be forgotten, for the very 

first case to which you are called may be one of this kind. 

Nor need there be any clashing or mischievous interference on 

account of what may be termed the surgical and the medical indi- 
cations sometimes presented by the same case. 

anddo S t e a7 andmedicinenot Tne uterns can be reposited, its cervix dilated, 
or the os uteri medicated topically, if needs be, 

while the constitutional treatment, based upon other and different 

indications, is still being pursued. 

IRRITABLE UTERUS. — HYSTERALGIA. 

Case. — Mrs. J , 27 years old, married, with three children, 

the youngest of which is two years of age, has been an invalid for 
nine years. She is naturally delicate and sensitive. She was mar- 
ried at eighteen, and left home directly for a wedding trip, which 
was to consist of an excursion to a distant city and a visit of a 
fortnight to her husband's relatives. When she reached home 
she felt as if her nervous system was very much shattered. She 
attributes this result to a want of entire sympathy and accord with 
her husband, who, she says, never understood her, and never took 
any especial pains to please or to gratify her. During her girlhood, 
after fourteen, she suffered a great deal at her monthly periods, 
more especially for the first ten or twelve hours. For this she 
usually took hot teas, and gin, and kept to the bed. Since the 
birth of her children this dysmenorrhea has not returned, but she 
has not been well for a moment. Her chief complaints are of a 
fugitive character. She is wretched when she goes out, and when 
she comes in ; in the morning and at night. The only pains that 
she has are snooting, shifting and transient, mostly in the lower 
part of the back and of the abdomen. At intervals she has spells 
of lying in bed with these pains for several days. Sometimes 
there is strangury, particularly after coitus, which always worries 
and unnerves her. Menstruation is regular, but less free than it 
should be. She is most happy when in general society. When 
she can forget herself, and be thoroughly diverted, she feels like 
another person. For this reason she likes to go away from home 
on a visit. Her nights are wakeful, and she dreams of every 
event, whether pleasant or painful, in her past life. Her feet are 
always cold. 

Examination does not reveal any sign of organic disease about 
op within the pelvis. The uterus is very irritable and tender to 
the touch. It seems to be slightly enlarged, but is not displaced. 
When the finger comes into contact with it she says it produces 



ON THE DISEASES OF WOMEN". 481 

the same painful tension and disagreeable feeling which she has 
always experienced during intercourse, and which is so intolerable 
to her. 

There is a large class of diseases, of which this case is an exam- 
ple, in which the obvious organic lesion of the uterus and its 
appendages is the poorest possible criterion of the real nature of 
the complaint, of the suffering involved, and of the difficulty of 
curing it. The irritable uterus is not inflamed or ulcerated, con- 
gested or displaced. There is no lesion of 

Has no definite lesion. . 

structure connected with it necessarily. It 
yields no characteristic or critical discharge. Its measurements 
are normal, its regional anatomy is unchanged, and it offers no 
especial obstacle to menstruation, conception, or parturition. 

So far, therefore, as its morbid anatomy is concerned, it resem- 
bles nitrogen in being negative in its character ; for it consists 
essentially in an excitable or irritable condition 

A'species of hyperesthesia. ,.,.,. , . 

oi the womb, in which its nervous sympathies 
and relations are exaggerated and discordant. Inflammation of 
this or adjacent organs may exist as a sequel, or complication, but 
they are not a necessary part of the disease. So, also, in some 
cases there are incidental symptoms of spinal irritation, and of 
reflex disorders of every conceivable kind, which are contingent 
upon the morbid exaltation of uterine sensibility. 

This disease is limited for the most part to menstrual life. It 
occurs in the case of the married and the unmarried, but is more 

frequent among the former. Those who have 

Limited to menstrual life. 

been pregnant, whether they have gone to term 
or not, are believed to be more subject to it than such as have 
never conceived. There are, however, many exceptions to this 

rule. In general, those women who are weak, 

Predisposing causes. . 

nervous, and impressible, and who have been 
subject to slight, spasmodic and painful irregularities of menstrua- 
tion, are very prone to this disorder in after life. Unhappy mar- 
riage, the loss of property and of position in society, the lack 
of occupation, disappointment, solitude, the dread of having 
some "female weakness," inordinate use of tea and coffee, 
chagrin, jealousy, frequent abortion, too rapid child-bearing, 
erotic thoughts, and sexual excesses, belong also to this class 



482 LECTURES, CLINICAL AND DIDACTIC, 

of causes. The rheumatic and neuralgic diatheses are powerful 
predisponents of this form of hysteralgia. 

The exciting causes are also numerous. Whatever can directly 
or indirectly exalt the nervous susceptibilities and sympathies of 
the uterus (even if the stimulant be natural 
and harmless under different circumstances) 
is likely to work mischief if too frequently and carelessly applied. 
The emotions, which properly controlled are healthful and useful, 
may be in league with the passions to derange the uterine nervous 
system, and either or all of the functions connected therewith. 
Under their influence the womb may become so irritable that 
menstruation shall be suppressed, or become intermittent, scanty, 
profuse, or perhaps very painful, Or, through the uterine irrita- 
bility that is induced, a fruitful intercourse may be impossible, 
and sterility will be the result. 

Ungratified sexual desire is undoubtedly almost, if not quite, as 
injurious to the female in many instances as an excess of venery. 
For women are not only subject to sexual passions and propensi- 
ties similar to those of men ; but they are also under the dominion 
of a periodical crisis, that is attended by a peculiar exaltation and 
excitement of the generative system. These crises can not 
always be passed with impunity. They involve certain vicissi- 
tudes which derange the uterine innervation. And coming as 
they do so frequently, these nervous derangements are perpetu- 
ated. It is sometimes as difficult to tide a woman over "the 
month " as it is to carry a popular patient, who is very ill, over 
the Sabbath, or through a holiday, without a relapse, or an exac- 
erbation of his disease. The contingent excitement and re-action 
are so mischievous that it is almost impossible to counteract them. 
The result is an irritable condition of the uterus and of the whole 
sexual system. 

Other causes of this kind are the fitful, too frequent and incom- 
plete performance of the sexual act, without regard to the menses, 
or to the emotional state and desire of the female ; exercise, as in 
riding or walking while menstruating, or directly after the flow 
has ceased ; getting up too soon after delivery, and especially 
after abortion ; too prolonged lactation ; frequent miscarriages ; 
the use of harsh or cold injections with a view to prevent concep- 
tion; constipation, from paralysis of the rectum ; dancing, skating, 



OX THE DISEASES OF WOMEN. 483 

horseback riding, blows and falls upon the spine ; excessive or 
constrained muscular effort, as in running the sewing-machine, 
prolonged standing upon the feet, or sitting in a confined posture 
at a desk ; prolapsus, retroversion or retroflexion of the uterus ; 
pressure of the bladder, of the bowels, of the ovaries, or of some 
pelvic or abdominal tumor against the womb ; spasmodic and me- 
chanical obstructions of the cervix uteri ; ulceration of the vagina 
or vulva ; nymphomania ; vaginismus, and ovarian irritation. The 
uterus is generally exempt from this form of irritation until after 
puberty. 

Some of the most intractable and painful cases of irritable 

uterus that I have ever treated have occurred in those women 

who, having been married for several years, 

From an early abortion. i-it t 

have had no children. In many 01 them con- 
ception took place almost immediately after marriage, but for 
reasons which seemed to them to be justifiable at the time, and 
without any adequate idea of the harm involved, measures were 
taken to force the flow, and, in short, to bring en an abortion. 
These measures were successful. The uterus was emptied of its 
contents. But the indirect consequences remained to torture 
them, and to impair their health and happiness for years to come. 
I could tell you the story of more than one beautiful woman who 
has suffered with this trying disease, whose health has been 
ruined, who has remained childless, and who would give the 
world if, when she was the bride of a few weeks, she had not 
swallowed somebody's "never-failing pills," or taken the wretched 
advice of a neighbor in this respect. 

Another fertile source of this uterine irritability is the reckless 
cauterization of the cervix of which I have already spoken so fre- 
quently. There are certain subjects upon 

From escharotics. . _ n 

whose delicate organisms this species ot refined 
cruelty reacts with a most damaging effect. And it is a singular 
fact that those physicians who resort to it habitually become 
blinded to these results and indifferent of the consequences. Let 
me cite you a case to which I was called yesterday : 

Case. — Mrs. , an intelligent, active woman of twenty-two, 

of nervous temperament, mother of one child two years old, lias 
not been well for six months. Her household cares, and the worry 
with servants, the heat of the weather, and having to entertain an 



484 LECTURES, CLINICAL AND DIDACTIC, 

avalanche of friends, had worn her down, and she was reduced in 
strength and spirits. She had no positive symptoms to complain 
of, excepting that she suffered from more frequent and severe at- 
tacks of sick headache (to which she was accustomed) than usual. 

For some weeks she tried to cure herself by means of domestic 
remedies from her own case, and finalty by tonics of various kinds 
at the prescription of some of her friends. But her symptoms 
remained as before. She continued her household drudgery, did 
her own shopping and marketing, and, as usual, went to church 
and to Sabbath-school. 

Finally, through the advice of a neighbor, she consulted a lady 
physician, who cauterized the neck of the womb, and continued 
to do so twice each week, excepting the menstrual week, for six 
weeks. From the first application, she felt herself very mnch 
injured, and made worse ; but was advised to persevere, on the 
theory that, when she had once passed this purgatory, her feelings 
and experiences would be blissful enough. Each repetition of 
this cruelty unnerved her more and more. She could not sleep, 
but walked the floor at night, lost her little remaining appetite, 
had cold, fainting spells, in which she would be unconscious for a 
long time ; she became discouraged and disheartened, melancholy, 
and, so her husband told me, practically insane for many hours 
after the caustic had been used. With this there developed a 
most tormenting strangury, and, after the second week, a corro- 
sive, itching leucorrhcea, although she had never had the slightest 
sign of either of these complaints before. 

At the end of the seventh week, after having had twelve of 
these " treatments," she deliberately came to the conclusion that 
her health would be utterly ruined should she persevere in this 
course. She therefore relinquished it, discharged her physician, 
and sent for me. 

Symptoms. — It would be quite impossible to give you all the 

symptoms of this curious disease in detail. In general the pain 

that is experienced is disproportionate to the 

Location of the pain. . 

uterine lesion. It varies m its seat, and char- 
acter also. Usually it is located somewhere in the lower part of 
the back, or within or near the pelvis ; but very often it is situated 
in the head, the spine, the chest, or the abdomen. The pains are 
transient, paroxysmal and neuralgic, being for the most part, 
unaccompanied by any profound or peculiar constitutional dis- 
turbance. They are greatly influenced by emotional states, being 
either aggravated or relieved by certain conditions of the mind. 
Posture modifies the recurrence and severity of the paroxysms. 



motion. 



OX THE DISEASES OF WOMEN. 485 

Most women who have an irritable uterus find it difficult to main- 
tain an upright position for any considerable 
Effect of posture and of i eil ath of time. They can not stand or sit more 
than a few minutes without great suffering, and 
going up and down stairs is almost impossible for them. Often 
the reclining posture is the only one that can be tolerated. They 
may have a mortal dread of defecation and of urination, either of 
which is apt to be followed by extreme pain, exhaustion or faint-, 
ness. Sometimes there is an irresistible desire to pass water, 
especially when she lies down ; again the urging to stool is equally 
tormenting whenever she sits up. And still the urine may be 
unchanged in quality, and the bowels remain costive. 

To these symptoms we must add those which simulate certain 

local disorders, as in the mimicry of Hysteria. The most common 

of these are dyspnoea, aphonia, palpitation of 

£May simulate other dis- ^he ;h ear t, angina pectoris, pleurisy, neuralgic 

pains in, and swelling of the breasts, especially 

before or during menstruation, ovarian aching and irritation, 

headache, facial and orbital neuralgia, gastrodynia, dyspepsia, 

chronic vomiting, depression of spirits, monomania, numbness of 

the extremities, muscular paralysis, and stiffness and uselessness 

of the joints. 

The nervous symptoms include insomnia, flatulent distention of 
the abdomen, dejection of spirits, emotional distress, great fluctu- 
ation of the feelings, sourness or suspiciousness 
of temper, loss of self-control, lassitude, indif- 
ference, hypochondria, extreme sensitiveness to ridicule or to 
reproach, fickleness, jactitation, unrest, local or general spasms, 
tremors, partial paralysis, and circumscribed alterations in the 
temperature of the part affected. 

Of course these symptoms are not all present in every case of 
irritable uterus, but for every one of them that is lacking, you 
may find that ten or twenty others have been 
cio S us mptoms may be caprI " a^ed. In brief, the symptoms are subject to 
the same variations, and are many of them as 
inexplicable as they are in hysteria, to which disease this affection 
is so closely allied. They are generally aggravated at the month, 
and are largely influenced by the state of the patient's emotions. 
She may be suffering severely, for example, with a pain which 



486 LECTUKES, CLERICAL AND DIDACTIC, 

alarms her family and makes her seriously ill. A friend calls to 
invite her to a drive, or a visit, and forthwith the symptoms van- 
ish. The family are horrified at her going out so soon ; and the 
doctor, who left her an hour before at home, may meet her miles 
away on a mission of mercy or of pleasure. 

Such a patient, who can not sit upright in her chair for five 

minutes consecutively, will sometimes get into her carriage, and 

, in a half-reclining posture, ride by the hour, or 

Contradictory nature of. o j- 

all the day long, without the least sign of 
fatigue or suffering. Or she will manage the affairs of her household, 
of the church, or of some charitable enterprise, with all the exec- 
utive ability of one who is well and able to withstand any amount 
of fatigue. And yet, in so far as the mastery of her own move- 
ments is concerned, she may be as helpless as an infant. 

An examination per vaginam, as in the case of Mrs. J., reveals 
a more or less sensitive condition of the womb. The cervix is 

tender to the touch, and if you push the organ 

Physical examination. -i.t • , • . • , • ,t 

toward the superior strait it pains the patient 
exceedingly. In some cases the pain upon pressure is limited to a 
small spot. The most delicate manipulation Avith a view to intro- 
duce the sound or the speculum occasions more of suffering than 
usual. Sometimes the uterus feels swollen and slightly enlarged. 
Occasionally it is more or less prolapsed, and in very rare instances 
it is either retroflexed or retroverted. 

Diagnosis. — This disease is sometimes confounded with coccy- 
odynia. But, in coccyodynia, whether from an injury sustained dur- 
ing labor, or from a fall or a blow, the patient 

From coccyodynia. 1 . . 

can not sit down squarely, or rise again without 
immediate and most excruciating pain, which is always referred 
to the point of the coccyx. In irritable uterus the pain is not 
always so limited, and she can usually sit from five to fifteen min- 
utes before the pain and the ill feeling come on. In the former 
the reclining posture is as painful as the upright one in sitting ; 
but not so in the latter. In the former there is likely to be a great 
increase of the neuralgic pain while at stool, and pressure with the 
finger in any direction induces a local paroxysm ; in the irritable 
uterus the suffering at stool is such as usually attends a consti- 
pated state of the bowels, and pressure upon the coccyx does not 
cause any very distinctive or extreme pain. 



OX THE DISEASES OE WOMEN. 487 

You would differentiate this affection from organic diseases of 
the womb by the absence of such discharges as are produced in 

uterine ulceration, and leucorrheea. It need 
D F smTnor?h£a disease '~ no t be confounded with dysmenorrhoea, for in 

irritable uterus, although it is apt to be worse 
at the month, the pain recurs without any regard to menstruation, 
and often continues from one month to another. 

Treatment. — Whatever predisposition the patient may have 
inherited or acquired should, if possible, be removed, in order 

that the proper remedies may work more effi- 

Remove the cause. . _ r» i -tit 

ciently. bo also 01 the avoidable causes, pro- 
viding you can determine what they are, which in some cases is 
extremely difficult. To fulfil these indications may require much 
time and an infinite deal of tact, but, if you have the full confi- 
dence of your patient, and are sufficiently persevering, you will 
succeed in making life tolerable to her, if not in performing a rad- 
ical cure. 

In general you should remember that this class of patients are 

weak, debilitated, and badly nourished. If they take a sufficient 

quantity of food, it does not build them up as it 

Buna up the general should. Their vitalforce is low, and their strength 

strength. ' o 

is below par. They are too prone to depend for 
subsistence upon tea and toast, and crackers, and various little delica- 
cies which can not sustain them properly. They are very apt to 
loathe meat of all kinds, milk and all varieties of animal food, 
and from their habits in this regard to develop a species of neu- 
ralgic dyscrasia, which frequently underlies and may even cause 
the worst form of hysteralgia. 

The first thing to be done for such patients is to fortify their 
general strength and vigor by stimulating their digestion, and 

supplying them with the proper aliment. In- 
The mode and time of s t e ad of mincing their meals and eating under 

eating. o o 

protest in their rooms, apart from the family 
and alone, they should be brought to the table with others and 
tempted to eat more freely of good, substantial food. Let them 
" follow copy," as the printers say, and imitate those who have 
better appetites. 

The fresh air and sunlight are indispensable ; but the amount 
and variety of exercise to be taken must depend upon the patient's 



488 LECTURES, CLINICAL AND DIDACTIC, 

original strength, and the peculiar complications and history of the 
case. The more marked the hysterical tendency, 

Fresh air and exercise. -i r* •i-i i . t 

the greater the need ot will on her part, and 

determination to overcome the physical obstacles that lie in her 

path. Some of these patients need almost to be put out of doors 

before they will make the necessary effort to walk or ride, and 

thus learn for themselves that locomotion is among the possibilities. 

But it will not do to insist that all are alike in this respect. For, 

on the contrary, some of them will go too much and too far. They 

overdo in this direction, and need to be re- 

varyin- ability to take strained. And others are absolutely too weak 

exercise. J 

and too ill to take active exercise, regardless of 
its cost or consequences. The best rule with which I am acquaint- 
ed is to observe carefully how each one is influenced by the effort 
of going to ride or to walk, and thus to learn what she can bear 
and take within the limits of actual fatigue. She may be able to 
ride three squares not only with impunity, but with decided bene- 
fit, when to add one more square to the length of the drive would 
do her a positive injury. Long journeys are more tolerable for 
this class of our patients than they were before the days of the 
sleeping-car, but notwithstanding this improvement, many are yet 
injured by travel on the railways. When it is possible, and con- 
venient, it is best for them to journey by water. 

You will have so much trouble in regulating the habits of some 

of these patients in many particulars, that I am tempted to let you 

into a little secret which may help you to carry 

A practical hint. •in 

your point, and to adapt your counsel to the 
end in view. First, make up your mind deliberately what prac- 
tice, or habit, or influence it is that lies in the way of their re- 
covery. Then set to work to reform or to remove that custom or 
influence, whatever it may be, by gaining the entire and willing 
assent of the patient herself. These indications cannot always, 
or perhaps frequently, be met in an off-hand or intuitive manner. 
They require the exercise of thought and of tact. And unless you 
can secure her confidence and co-operation, you certainly will not 
succeed. It may need a large measure of skill and of perseverance 
to bring it about, but you will learn that the art consists in hav- 
ing your own way, while she is under the impression that she has 
hers also. 



OX THE DISEASES OF WOMEN. 489 

A very common error in the treatment of the irritable uterus is 

to suppose that uterine surgery, as it is technically styled, and 

j ordinarily practiced, will help to cure it. For 

Surgery contra-indicated. . 

the truth is that, m this class of cases, it does 
more harm than good. There is not a single operation, or expe- 
dient of this kind, that is advisable in an uncomplicated case of 
hysteralgia. Caustics, the knife, the sponge-tent, the bistourie 
cachee, the sound, the probe, and pessaries of whatever variety, 
are so many instruments of torture. They invariably aggravate 
the disease. It is only when some of the incidental conditions 
that require such aid are superadded to the irritable condition of 
the uterus itself that the intelligent physician employs them in 
this disease at all. 

For the relief of the spinal, sacral and pelvic pains various 

topical applications are permissible and useful, the same as in 

other forms of neuralgia. Bathing the back 

Topical expedients. -. „ . 

with salt-water, dry motions along the spine 
from above downwards, hot or cold water locally, the shower 
bath, pediluvia, wearing a thick layer of cotton batting along the 
back, the wearing of silk undervests and wrappers to insulate 
and protect the person against sudden electrical changes, paint- 
ing the painful part with the oleaginous collodion, dry cupping, 
porous plasters, arnica plasters, magnetism, electricity, galvanic 
belts and plates, and the use of bland and soothing injections per 
vaginam are the most common and useful of these expedients. 

I once called an old physician in counsel in a case of diphtheria. 
We had agreed upon the internal remedies, when my friend sug- 
gested that something, and the simpler the 

Why we should use them. -i-i-it -tip 

better, should be prescribed lor external use, 
chiefly in order to keep the nurse and watchers busy with that 
which would do no positive harm, even if it did but very little 
good; for, said he, you know that "Satan finds some mischief 
still for idle hands to do." 

Acting upon this principle, and remembering the propensity 
of human nature to overdo in the matter of nursing especially, 
you had better advise some simple expedient that will "keep the 
nurse and watchers busy," rather than let them " fly to evils that 
they know not of." 

It is unnecessary to repeat what I have already said of the 



490 LECTURES, CLINICAL AND DIDACTIC, 

choice of remedies when speaking of the treatment of hysteria.* 
There is no specific for the relief and cure of 

No specific treatment. . . T „ . 

the irritable uterus. It the proper conditions 
are supplied and secured, medicines will achieve the most marked 
results. Otherwise they are powerless. The symptoms are so 
complicated, and oftentimes so contradictory, that you will find 
it very difficult to choose the most appropriate remedy. 

It is very probable that among the newer remedies, which of 
late have attracted so much attention, we may yet find a more 

ready means of cure for the various nervous 

The new remedies in. . . , 

disorders which are symptomatic ot uterine dis- 
ease and irritation. For myself, I have come to place a deal of 
confidence in macrotin, gelseminum, caulophyllin, the lilium tigri- 
num, and senecin. Other members of this class are Scutellaria, 
ambra grisea, cypripedium and veratrum viride. But the old 
polychrests should not be forgotten. 

Mrs. J. will take a dose of macrotin three times daily, and have 
electricity applied along the spine twice per week — every Tues- 
day and Fridav evening. I think it best in 

Prescription. . .. . 

these cases that electricity should be used in 
the evening rather than in the morning or the early part of the 
day. She must also play the part of a good Christian philoso- 
pher, and not let her little domestic cares and trials fret and 
worry her too much. 

* See page 315. 



ON THE DISEASES OF WOMEN. 491 



LECTURE XXIX. 



THE UTERINE SOUND. 



Gentlemen : 

While we are waiting this morning for our first patient to be 
brought in, I will speak of the Uterine Sound. And in order to 
make my remarks as practical as possible, I will arrange them so 
as to consider (1) why, (2) when, and (3) how we should avail 
ourselves of this invaluable instrument. 

1. Why, or for what purpose do we employ the sound? 

You are doubtless aware that this instrument, of which you will 
find several varieties upon the table, has been in use for 
centuries. By the ancients it was regarded as 
a curative means. They scarcely used it for any 
other purpose than to replace the uterus when it had become dis- 
located. But, in the hands of modern gynecologists, it is regarded 
almost exclusively as an aid to diagnosis. In this manner it enables 
us to diagnosticate : 

(a.) Certain Diseases of the Uterine Cervix. — If we know what 

the proper dimensions and length of the neck of the womb are, or 

should be, by passing this instrument, we can 

In diseases of the cervix. -,.,.« • at 

decide it the case is one ot hypertrophy, atrophy, 
or immobility of this part of the organ ; if it is imperforate ; if 
there is cervicitis, or a polypus, or uterine displacement. Atresia, 
obliteration and flexures of the cervix, as well as a more or less 
permanent closure of the internal os uteri, in mechanical and spas- 
modic dysmenorrhea, are also recognizable by means of the 
sound. 

(6.) In diseases affecting the cavity and body of the uterus. — The 



492 LECTURES, CLINICAL AND DIDACTIC, 

very ease of introduction of the sound through, the internal os 

uteri, during the inter-menstrual period, sug- 

in diseases of the uterine crests that all is not right within the cavity of 

cavity. & o J 

the womb. It is a sign of endometritis, or of 
the presence of some foreign growth, as, for example, either sub- 
mucous or interstitial fibroids, polypi, hydatids, cauliflower ex- 
crescence, or of cancerous degeneration. 

(<?.) To measure the size of the uterus. — In health the unimpreg- 

nated womb measures about two and a half inches from the os to 

the fundus uteri. But this organ is so disten- 

For measurement. . .. .. . 

si ble, so given to development and to variations 
in its size and capacity from pathological, as well as from physio- 
logical causes, that we may sometimes learn much in a diagnostic 
way from its actual measurement. This, of course, is best accom- 
plished by means of the uterine sound. Passing the instrument 
in the direction of the axis of the organ, through its whole length, 
and taking care to indicate the extent to which it has entered the 
uterus, we obtain the longitudinal measurement of that organ. If 
it is lengthened to four, six, or more inches, and the woman is not 
pregnant, or has not very recently been delivered, the informa- 
tion thus obtained makes us confident that something is wrong. 
By this means, therefore, we may be able to 
diagnosticate a longitudinal hypertrophy of the 
womb, a very interesting case of which I will take an early occa- 
sion to show you. By it, also, we may detect sub-involution and 
super-involution, as well as enlargements of the uterus due to the 
development of various kinds of tumors, as, for example, uterine 
fibroids, within its cavity. Thus, in the case of Mrs. H., you will 
remember, although she had a large ovarian cyst which was re- 
moved in presence of the class, the uterus measured six inches, 
and was found upon actual inspection to be very considerably 
enlarged.* In order to be accurate in this kind of measurement, 
it is well sometimes to use the graduated sound. 

(t?.) To test the mobility of the Uterus. — In not a few cases the 
non-susceptibility of the uterus to motion is a diagnostic test of 
great value. We apply this test by introducing the sound, and 
then observing whether, when we move it laterally and carefully, 
the womb moves along with it. If it does, the organ is free, and 

*See page 363. 



ON THE DISEASES OF WOMEN. 493 

not bound down by adhesions or organic change ; but if it does not, 
some pathological change has been going on which has resulted 
in its becoming glued or adherent to the neighboring parts. 

This sign is present in cancer of the inferior segment of the 

womb, and in certain confirmed cases of pelvic cellulitis, and 

more frequently in pelvic-peritonitis. We also 

In uterine carcinoma . _ . .. . 1 

meet with it, but more rarely, in old, chronic 
cases of retroversion and of retroflexion of the womb, in which 
the organ is anchored, so to speak, by strong adventitious bands 
attached to the rectum and the posterior pelvic tissues. 

This, as you know, is one of the means of differentiating 
between uterine and ovarian and other abdominal tumors. Plac- 
ing the left hand over the abdomen, and mov- 

In uterine tumors. _ 

mg the sound in utero with the other hand, as 
I have just indicated, if the motion of the womb is communicated 
to the tumor, or, in other words, if the womb and the tumor move 
simultaneously, in the same direction and to the same extent, we 
are assured that the tumor is uterine. But if the uterus can thus 
be moved independently of the tumor, there is no doubt of its 
being extra-uterine. 

(<?.) In the diagnosis of Uterine Displacements. — It will occur 
to you, without doubt, that any considerable disorder of place in 

the womb would necessarily include a deviation 

In deviations of uterus. . . 

oi its axis from the normal one. The direction 
of its long diameter, and therefore of its curve, would be changed. 
Now, in order to ascertain what direction the luxated organ has 
taken, and the extent of the displacement, more particularly in 
versions and flexions thereof, we must depend almost entirely 
upon the sound. If the womb is in situ, what might be termed 
the pelvic curve of the instrument (as we speak of the pelvic 
curve of the obstetric forceps), looks forward, toward the sym- 
physis pubis, and the point thereof corresponds with the axis of 
the superior strait. But if the womb is bent forwards, or back- 
wards, or laterally, the curve or concavity of the instrument will 
be found towards the bladder, the rectum, or the right or the left 
iliac fossa, as the case may be. Sims' uterine probe, which is a 
modified or attenuated sound, is sometimes very useful in this 
class of cases. 

In prolapsus the sound enters more readily, and its point takes 



494 LECTURES, CLINICAL AND DIDACTIC, 

the direction of the axis of the inferior strait or of the vegina, 
and looks toward the hollow of the sacrum, or toward the sacro- 
vertebral eminence. In procidentia, the os being at the lowest 
part of the tumor, the sound may be readily introduced. By this 
means we differentiate between procidentia and inversion of the 
womb ; for, in the latter, the os uteri can not be found before the 
organ is reposited, and therefore in inversion it is quite impossible 
to pass the sound until that operation is performed. 

Of late years, as I have already said, the ordinary sound is not 
often used as a means of replacing the uterus. In exceptional 
cases, however, it ma,y still be used for this 
^Forthereposkionofthe purpose. Drs. Elliott, Sims, and others, have 
brought out such improvements upon the old 
instrument as render it much more safe and valuable as a means 
of fulfilling this indication. 

2. When should the Sound be introduced? 

I have known physicians to fail to learn anything from a resort 
to the sound because they did not have tact enough to discover, 
and no one had told them, that there were certain times and sea- 
sons in which this instrument could be used to more advantage 
than in others. As a rule, I think you will find that the sound 
can be more readily passed in the early than in 
the later part of the day. If you can be per- 
mitted to make the operation early, before the patient is up, or 
has been upon her feet in the morning, it may be much more 
easily and thoroughly accomplished than if you wait until toward 
evening or bedtime. 

Sometimes it is well to select a time which is a few hours, or 
perhaps a day in advance of the menstrual period. The prepara- 
tory dilatation having been effected in advance 
! I ^ vanceofthemonth - of the flow, the internal os uteri is lazily agape, 
and less irritable than usual, and the sound 
is made to enter with but little delay, pain or trouble. 

You would not attempt to pass it when the patient is very 
much alarmed or excited, agitated and appre- 

When the patient is calm. . , . 

hensive. Neither would it be advisable in 
case of menstrual retention with softening of the cervix, lest the 



ON THE DISEASES OF WOMEN. 495 

woman might prove to be enceinte, and you might bring on a 
miscarriage. Nor would it do any good, but might possibly do 
harm, to introduce it too soon after menstruation, or directly after 
delivery. 

3. How shall it be passed? 

Unless the cervix uteri is closed by an atresia of its canal, which 
is comparatively rare, the chief difficulty in introducing the sound 

is met with at the internal os. This obstruction 
ter™m c . ulty at the M in " is caused either by a change in the course of the 

utero-cervical canal at that point, or by an 
irritable condition of the muscular fibres (which form a sort of 
sphincter about the orifice) which causes them to contract spas- 
modically on the approach of the instrument. 

It is a very common error to suppose that the healthy uterus is 
nearly straight, when in fact it is not so. Cruveilhier, and other 

anatomists, have shown that, even in little girls, 

Uterine axis not straight. ..,.■,.., » T 

its fundus is thrown forward, as in anteversion, 
toward the bladder. Opposite the junction of the neck with the 
body of the organ, there is a curve which is in the form of an 
obtuse angle, as is shown most clearly in this beautiful model, and 
in the diagrams on the black-board. 

Now, in order to enter the uterine cavity, the instrument must 
follow this curve at the internal os uteri, otherwise its point can 

not reach to the fundus. If the curve, or 

Variation in uterine curve. 

flexion forward, were uniform and unvarying, 
in different women, there would be little trouble on this account. 
But it is not so. For we find that, even in healthy persons, there 
is the greatest possible difference, not only in the shape, size and 
position of the womb, but also in the course and direction of its 
canal. This explains the fact to which I have before alluded, 
that, having learned the individual peculiarity of a patient in this 
respect by the passage of the sound, it will be less difficult to 
perform the operation upon her in the future. There are many 
exceptions, however, to this rule. 

It is because of the varying course and curve of the uterine 

canal in different subjects, and in health and 
P rSerabL f . soundthatis disease, that it is best to use a flexible sound, 

which is capable of adapting itself to the exist- 
ing curvature, instead of a very stiff one, which would not yield, 



496 lectup.es, clinical and didactic, 

and which would require more of force to introduce it. For this 
reason, the copper sound, and in some instances the whalebone 
probe, is preferable to Simpson's old-fashioned sound. This 
copper sound will insinuate itself, whereas in a considerable pro- 
portion of cases, the old one can not be introduced without an 
unwarrantable decree of force. Where the uterine canal is bent 

o 

acutely, forming an elbow, or the uterus is twisted upon itself 
spirally, we may sometimes pass a Sims' probe, such as I hold in 
my hand, and then withdraw it so carefully that it will retain its 
shape. The larger sound can then be bent into the same form, 
and afterwards passed more readily. 

Concerning the best position for the patient to assume, some- 
thing will depend upon the nature of the case which is to be 
examined. Usually, it is best for her to lie 

Position of the patient. 

upon her lett side, on the bed or couch, to have 
the thighs flexed on the abdomen, and the legs on the thighs. 
This will enable you to find the cervix most readily, and to give 
the proper direction to the point of the instrument, when it has 
passed into the cervical canal. If she lies upon the back, and the 
uterus is not prolapsed, more especially if the vagina is long and 
your index finger is short, you will experience considerable diffi- 
culty in reaching the neck of the womb at all. And when you 
have reached it, the ringer will come against the anterior lip, and 
the organ will recede into the hollow of the sacrum, so that it 
may be next to impossible to pass me sound even through the 
external os uteri. 

There are exceptional cases in which the womb is displaced in 

an upward direction, in which, no matter what the position of the 

patient, it is very difficult to pass the sound. 

An exception. . 

In these cases, it is recommended to let the 

patient stand upright, with her back against the wall, while the 

operation is being performed. But ordinarily this is not requisite. 

If there is retroversion or retroflexion, the woman may be 

placed on the bed, couch or table, as for the introduction of Sims' 

speculum, on the left side, far over upon the 
wa\ds displacements back " abdomen, with the right thigh flexed and the 

left one straight. Or, if this is not sufficient, 
with the aid of gravity, to bring the fundus forwards, so that the 
sound may pass readily, she may take the knee-elbow or prone 



ON THE DISEASES OF WOMEN. 497 

position. In the latter case, before she gets upon the knees, you 
had better secure the cervix for fear it may recede and pass beyond 
your reach. This indication may be met by means of the uterine 
tenaculum, an ordinary vulsellum, or what answers equally well, 
and is less painful, by introducing the sound as far as may be 
before she turns over, then keeping it within the cervix while she 
is changing her position. 

In anteversion and anteflexion you may take the precaution to 

recommend her to lie on the back for a number of hours before 

you pass the sound. She should also be 

In displacements formed. . .. • -i i • , . . 

instructed not to void her urine unless it is 
absolutely necessary, for about the same interval, in the hope that 
its accumulation in the bladder may help to restore the womb to 
its proper position. Indeed, you should not forget that the full- 
ness or emptiness of the bladder and the rectum may greatly 
influence thu facility with which it is possible to pass the uterine 
sound. 

It is the habit of some physicians always to use the speculum 
as a means of facilitating the introduction of the sound. 

Since the invention of Sims' speculum especi- 

iuS°and "ounT ° f specu " a %> tn i s P rac ti ce nas become quite popular. 

My own opinion is that, while in rare cases it 
may be necessary to use these instruments conjointly, in ordinary 
practice we can get on quite as well, or even better, without the 
speculum and the tenaculum. You can learn to pass the uterine 
sound without the help of vision quite as soon and as adroitly as 
you can learn to pu,ss the female catheter by the sense of touch 
alone, and without any exposure of the patient's person. And I 
think you should try to do so. 

The chief things to be done in acquiring this species of tact are 
to place the patient in a proper position, to ascertain the direction 

of the uterine curve, to manipulate carefully 

Points to be observed. _ 

rather than forcibly, to nave the proper instru- 
ment, and not to be in too great a hurry. I have already spoken 
of the proper time and posture to be chosen. In order to learn 
the course of the uterine canal, the " touch" must precede the 
attempt to pass the sound. By passing the finger carefully on 
every side cf the cervix, as high up as possible, you can get the 
direction of the cervical axis, and recognize any marked flexion of the 



498 LECTURES, CLINICAL AND DIDACTIC, 

uterus, which is most apt to take place at a point opposite the 
internal os uteri, where the peritoneal coat is lacking in front. 
In case of the different versions the os and cervix must be located 
before the sound could be introduced. 

In ordinary cases, and with the tip of the right index finger at 
the external os, the sound can be passed along its palmar surface, 
while being guided by the left hand, and made 
to enter the canal of the cervix. When it has 
passed an inch or so within that canal, the handle of the instru- 
ment should be depressed toward the posterior commissure of the 
vulva, and its curve turned toward the symphysis pubis. A little 
delicate manipulation and tact will now cause it to pass through the 
internal os uteri and into the uterine cavity. Sometimes, how- 
ever, it may be necessary to withdraw the sound and to change 
its shape somewhat. Or it may have failed to pass because its 
point was lodged in one of the lacunae which are so numerous in 
the cervical canal. 

If you use too much force it is possible for the instrument to 

pass not into the uterine, but into the abdominal cavity. This is 

especially liable to occur in case the sound slips 

fo2e nger fr ° m t0 ° much anc ^ P asses i nto the Douglas' cul-de-sac ; and 
also where the tissues of the uterine cervix 

have been softened and somewhat disorganized as the result of 

chronic disease. Fatal peritonitis has sometimes resulted from 

this accident. 

If the patient is young and nervous, tell her precisely what it 

is that you propose to do ; that there will be no cutting, and but 
little pain ; that, in truth, this is only another 
means of extending the " touch" farther than 

the length of your finger will permit. Her attention should be 

diverted while the operation is going on. 

There is as much difference between two of these sounds which, 

to all appearance are precisely alike, as there is between two 
catheters. One will find its way like an intel- 

Choice of a sound. 

hgent agent, but the other almost invariably 
goes wrong. When you have selected a good one, let me counsel 
you to use it habitually and exclusively. 

Above all things do not be in haste. This a delicate little 
operation upon the careful performance of which more may depend 



OX THE DISEASES OF WOMEN. 499 

than you perhaps imagine. At any rate you will be more 
likely to fail than to succeed if you are rash and 

"Festina lente." ° J 

precipitate. It is Letter to take fifteen, twenty, 
thirty, or more minutes and do no harm, than to hurry the 
thing over without doing any good, or learning anything. If 
you fail altogether at one session, make another appointment with 
your patient, and try again. You may be more successful the 
next time. 

The instrument should be anointed with oil, lard or glycerine, 
or better still with soap and water at the dressing table. 



THE CLIMACTERIC — THE CHANGE OF LIFE. 

Cane. — Mrs. C. W , is forty-two years of age; has eczema 

of the hands and forearms. This eruption commenced one year 
ago and has continued ever since, being worse at times and then 
better. It is not an hereditary disease. She never had it but 
once before, which was in her thirteenth year. At that time it 
remained out for about six months and finally disappeared with- 
out any bad symptoms. Her general health has always been 
good. She has not been subject to any cutaneous disorder. She 
has five children, the youngest of whom is thirteen years old. Her 
menstrual life has not been peculiar in any respect excepting that 
she had some trouble when the flow was first established. This 
was in her thirteenth year. She was in poor health at that time 
for about half a year, and did not recover entirely until the flow 
came on freely and regularly and the old eruption had altogether 
disappeared. 

The life of woman is a succession of epochs, or crises. Puberty, 
matrimony, gestation, parturition, and lactation, bring their pecu- 
liar experiences and are beset by peculiar con- 
woSln 65 m the Hfe ° f tingencies. But there is still another epoch 
which has its physiological and its clinical his- 
tory. I allude to what is variously styled the " change of life," 
the "grand climacteric," the " critical age," the " cessation of the 
menses," the " turn of life," and the menopause. 

The age at which this period arrives in women varies as much 
in different individuals as does that which dates the advent of 
puberty. Indeed it bears such a general rela- 
tion to the early or late establishment of the 



menstrual function that we ordinarily estimate from puberty to 



500 LECTURES, CLINICAL AND DIDACTIC, 

determine when the catamenia should naturally cease. Thus, the 
usual duration of menstrual life is thirty years. If our patient 
was " unwell " for the first time when she was 
^Duration of menstrual i^ thirteen years old, and we add thirty to that 
number, we shall have forty-three } r ears as the 
most natural limit for the return of the monthly cycle. If, 
instead of beginning at thirteen the function had failed until she 
was fifteen, then she would most naturally continue to menstruate 
until she had reached the age of forty-five years. 

But this calculation is approximative, and not exact. We must 
make allowance for modifying circumstances of various kinds, 
among which hereditary peculiarities are, per- 
haps, the most marked. There are families in 
which all the women cease to menstruate prematurely at as early 
an age as thirty, others at thirty -five, and still others in whom the 
menopause is adjourned until fifty, or even to the 60th year, when 
it degenerates into a species of sexual haemorrhage. In these 
cases the advent of the change of life bears no particular relation 
to the age of the individual at the time that puberty was estab- 
lished. It not unfrequently happens that those who begin to 
menstruate the earliest continue to do so for a longer period than 
those who began later in life. 

Physiologically considered, the " change " which closes and 

terminates a most important function of the female economy, is 

truly an eventful and a marvelous one. It must 

Importance of the change. . 

work such a complete revolution as to invest 
this crisis with numerous contingencies. For this function, which 
represents the maternal instinct and relation, which made it pos- 
sible for the woman to become a mother, which was suspended 
while the child was being developed in utero, and while she 
nourished it at the breast ; and which was restored again in due 
season, is not one that can be begun, continued for so many years, 
and then stopped, without great expense and risk to the general 
organism. 

Hence we find that the approach of the climacteric predisposes 

women to various diseases which are of a more 
thfs'periJd. 5111011 inddent t0 or less serious nature. And, what is very 

strange, it not unfrequently happens that the 
disease from which they may have suffered at puberty re- 



New disorders induced. 



ON THE DISEASES OF WOMEN. 501 

turns. It is so. in the case before us. The class of affections 
which are most likely to recur in this manner are eruptive and 
nervous disorders, and haemorrhages from certain mucous mem- 
branes. In cases of this kind, it may happen 
be?t ise ma e r S r i e n tur d n nt t0 pu ~ tn at many years have elapsed without any sign 
of the difficulty, but when this change begins 
to take place the first symptom noticed is the reappearance of 
the old enemy. Very nervous and plethoric women are more 
likely to suffer in this manner, and indeed to be ill, at the change 
of life, than those who are of a lymphatic temperament. 

But in this respect the menopause is not absolutely or always 
in relation with puberty. Very often the experiences that have 
intervened since the woman first began to men- 
struate have so changed her nature that she has 
acquired a predisposition to other and different diseases. Preg- 
nancy, labor, and lactation, leave their impress upon her organi- 
zation, and it is as impossible for her youthful susceptibilities 
always to return, as it would be for her to become the same in 
feeling after the change of life that she was in her girlhood. 

Another peculiarity worthy of note is that many diseases are 
cured, or disappear in consequence of the climacteric. The ova- 
rian atrophy and paralysis removes a constantlv 

Old diseases cured by. . - , . ,_., , , J 

recurring source ot disease, lhe monthly cycle 
and its attendant excitement of the nervous, vascular, and 
glandular systems is withdrawn. A season of continued quiet, 
and comparative tranquillity supplies a favorable condition for the 
restoration of health. And when the critical period has passed it 
is found to have been the scape-goat of a thousand ills. Slender 
women may become corpulent and even obese, bed-ridden invalids 
get up and walk, and an entire and radical change of physical 
condition is the consequence in those who escape the perils of this 
period. They enter upon a new phase of life, with new hopes 
and relations towards the present and the future. 

Symptoms. — The manner of approach of the critical period 
varies in different individuals. With some women the change is 
abrupt, but with the majority it is more prolonged and gradual. 
Not infrequently the flow becomes intermittent, or, rather, the 
periods become irregular. One, two, three, or perhaps six 
months, and sometimes a year or more, may elapse between them. 



502 LECTURES, CLINICAL AND DIDACTIC, 

111 many cases they are too frequent, as well as too profuse, for a 
season, and afterwards are more tardy and abnormal in this 
respect. 

In a considerable proportion of eases the amount of the flow 

lessens gradually, so that it may finally come away drop by drop. 

or until there is nothing of it left. But as the 

Haemorrhage. _ 

change approaches, many women una them- 
selves flowing more freely than ever before. Indeed, the tend- 
ency of the catamenial discharge to develop into a haemorrhage is 
often observed. Out of 500 women at the change of life, Tilt 
observed that 208 had haemorrhages of various kinds. Of these, 
188 had either a single terminal flooding, or successive floodings.* 
Other forms of haemorrhage, which are in a sense vicarious of 
the monthly flow at the climacteric, are haemorrhoids, entorrhagia, 
epistaxis, haemoptysis, cerebral haemorrhage and apoplexy, haem- 
atemesis, haematuria, bursting of varicose veins, bleeding from the 
ear, and cutaneous ecchymosis. In plethoric women these losses 
of blood are in a sense critical, and although they are often dan- 
gerous in themselves, yet as a kind of safety-valve, they are 
sometimes salutary. 

The sudden arrest of the accustomed flow, when the change 
comes on abruptly, and more especially in those who are in good 

health, is often the occasion of alarm with such 

Simulates pregnancy. . 

persons lest they be pregnant. This suspicion 
finds apparent confirmation in the coincident gastric derange- 
ments that not unfrequently ensue. There is something resem- 
bling morning sickness, caprices of appetite, a sense of fullness 
and discomfort, and pelvic bearing-down and aching which 
women recognize as very similar to, if not identical with the 
symptoms of early pregnancy. You will certainly be consulted 
in cases of this kind, and in making a diagnosis should not forget 
that some women cease to menstruate as early as the twenty-fifth 
year. 

Sometimes the most violent, and again the most persistent and 
intractable indigestion, colic, diarrhoea, haemor- 

Alimentary symptoms. 

rhoids, dysentery or constipation, come with the 
first symptom of the menstrual decline. In many cases, these 

* The Change of Life in Health and Disease. By Edward John Tilt, M.D., etc., 
London, 1S67, page 65. 



ON THE DISEASES OF WOMEN. ^Oo 

attacks are self-limited, and subside of themselves when the crisis 
has finally passed. In a few they supplement the catamenial 
flow, and may pass into the chronic form. 

The circulation is very irregular, as is shown by flushes of heat 
in the face and. elsewhere, local congestions to the head, giddi- 
ness, blushing and discoloration of the skin, 
Disorders of the drcuia- coldness, tingling and numbness of the ex- 
tremities, sudden outbreaks of perspiration, 
chilliness, rigors, and active hemorrhages. 

The nervous symptoms and sequelae of the climacteric are 

marked and sometimes very troublesome. In degree they vary 

from the slight mental perturbations, vulgarly 

Nervous symptoms. _ ,, r>i 

styled " the fidgets, to the most profound con- 
vulsions and paralysis. Headache, vertigo, nervous irritability, 
pseudo-narcotism, self-absorption, insomnia, jactitation, palpita- 
tion, dyspnoea, horrible dreams, fainting, erethism, depression, 
debility, twitchings, spasms, mania, and full-fledged hysteria are 
by no means uncommon at this period. Either of these affections 
may precede, accompany or follow the cessation of the menses. 
In many cases the disorder is ephemeral ; but in others it becomes 
seated and confirmed. Spasmodic affections are very apt to con- 
tinue, and to take on a regular periodical type, which is most 
difficult of cure. The ganglionic nervous system is always impli- 
cated. 

There is a form of epilepsy which is not unusual at this period. 

I have seen several cases of the kind that were 

in no way connected with the hereditary form 

of this disease. Only yesterday I was consulted by my friend, Dr. 

W. R. McLaren, for the relief of the following 

Case. — Mrs. -, aged forty-five, is now passing through the 

grand climacteric. The menses recur every four to six months. 
They are quite profuse. About eve^ seven weeks she has the 
epileptic seizure. There is no very strong muscular contraction 
or rigidity. The face is pale, and during the paroxysm there is 
stertorous breathing, with foaming at the mouth. The fit, during 
which she is quite oblivious to everything external, lasts about 
four minutes. After it she sleeps for three-fourths of an hour. 
The change of life commenced with her one year ago, at which 
time she first began to have the epileptic paroxysms. Epilepsy is 



504 LECTURES, CLINICAL AND DEDACTIC, 

not hereditary in her family, although her mother also had fits at 
the change of life. 

Disorders of the nerves of special sense are not infrequent- 

Deafness, blindness, aphonia, loss of the sense of taste or of smell, 

and of tactile sensibility in various portions of 

Disorders of the special t b e s ki n are among the more common of these 

senses. ' & 

affections. These complications are most apt 
to occur in weakly, nervous, debilitated women in whom, for some 
reason, the climacteric is very much prolonged or exhaustive. 

The respiratory system comes in for its share of the contingent 
ailments. Those women especially who are predisposed to pecto- 
ral complaints, who inherit this bias, and who 
^Sem asesoftherespirat ° rynaTe suffered some of the consequences of 
incipient organic disease of the lungs at or 
before puberty, are most likely to have something of the kind at 
the climacteric change. Perhaps the first thing noticed is a more 
or less copious spitting of blood, or a nervous, irritating cough, 
which by and by settles into a confirmed habit, and is accom- 
panied by free expectoration. In some cases these symptoms 
develop into a rapid decline, and the patient may not live more 
than a very few weeks. In others they subside of themselves 
when the first cause is removed, and the menstrual crisis is safely 
over. In not a few instances the boasted cures of phthisis pul- 
monalis are really to be ascribed to the fact that such cases as 
these are self-limited, and frequently get well of themselves. 

But, as you would suppose, it is the generative function and 
the sexual organs which are most seriously disordered in conse- 
quence of the final cessation of the menses. 
m?s°s r t d em 5 ° f the genera ~ Tnus Dr. Tilt* found that of 500 women at the 
change of life, 463 suffered from uterine affec- 
tions. Among these contingent disorders are uterine cancer and 
catarrh, cervical inflammation and hypertrophy, uterine ulcera- 
tion, haemorrhage, hysteralgia, leucorrhcea, displacements, tumors, 
hydatids, polypi, and fibroids. Either or all of these diseases are 
more serious if the patient has already suffered from them. 

Other complications are ovaritis, ovarian induration, atrophy 
and paralysis, the development of cystic tumors, and of ovarian 

*Op. citat., p. 82. 



ON THE DISEASES OF WOMEN. 505 

abscess, and hematocele. And still another disease of the 
generative system, properly speaking, is cancer 

Incidental diseases. r>ii -iit • 

ot the breast, the development of which appears 
in many cases to be hastened by the permanent arrest of the 
menstrual secretion. 

Women sometimes suffer from a species of rheumatism and 

others from neuralgia which worries them exceedingly, and may 

perhaps wear away their remaining strength very 

Rheumatism and neuralgia. _ . 

rapidly. Again these affections are combined, 
and either or both of them may be located within the pelvis. The 
arrival of the critical period may act as an exciting cause, and 
really occasion an attack of rheumatism in one who not only has 
never had it before, but who was thought to be free from any pre- 
disposition to it. I could cite you many cases of this kind, but it 
must suffice merely to call your attention to the fact itself. 

Prognosis. — Where serious diseases occur at the climacteric, or 
follow it almost immediately, you will be puzzled in your prog- 
nosis. Eminent authorities are of opinion that 
The general health the t ] ie ovar i an activity is commensurate with the 

best criterion. «/ 

constitutional vigor ; and that, as a rule, life is 
longest in those women in whom puberty is retarded and the 
menstrual function most prolonged. Therefore, it will be a safe 
criterion upon which to base an opinion if we say that the 
patient's previous health (especially in so far as ovulation is con- 
cerned) has been good or ill, habitually. If she has been weakly 
and sickly, and suffered from menstrual derangements, such as 
dysmenorrhcea, menorrhagia, and amenorrhcea, or her nutritive 
resources have been sapped and drained by a chronic leucorrhcea, 
or diarrhoea, or mal-medication, or starvation, whether mental, 
moral or physical, the case is not of the most hopeful kind. The 
same is true of the bad effects of scrofulosis, and of too rapid 
child-bearing, as tending to undermine the general health and 
vigor, and to leave the patient a more easy prey to the contingen- 
cies that beset the menopause. 

We are therefore compelled to make due allowance for previous 
ill health, and to qualify our prognosis ; for it is a crisis through 
which the woman must pass, and whether she will survive it or 
not, will depend very largely upon the stock of strength that she 
has in reserve to beoin with. 



506 LECTURES, CLINICAL AND DIDACTIC. 

Critical eatamenial haemorrhages are dangerous, not because, 

as the ancients believed, that certain poisonous matters from the 

menses are retained in the blood-current, and 

Cause of the danger. . 

need to be eliminated, but because of an over- 
whelming afflux of blood to a delicate tissue or organ, which mav 
soon result in disorganization and death. 

If the cessation of the periodical flow shall re-act upon the 
lungs, and light up the tuberculous diathesis, it will not be safe 

to promise to cure the patient. And so, also. 

The tuberculous diathesis. r» -i • i t i 

of the alimentary disorders, of which 1 have 
spoken : for, although some of these utero-intestinal affections 
subside of themselves, when the menses are entirely disposed of. 
still in many other cases they only run a more rapid and fatal 
course. 

Treatment. — The critical period, therefore, is beset with so 
many dangers that its treatment becomes a very important mat- 
ter. The first thing to be done is so to regulate 

Hygienic rules. . 

the habits and surroundings of the patient as to 

protect her against these dangers. The state of her mind, the 

amount and variety of her physical exercise, and her food, must 

be prescribed and regulated according to the rules of hygiene and 

of good, sound common sense. Nothing wears upon a woman who 

has reached the turn of life like a want of sleep, of rest, and of 

freedom from the petty cares and annoyances which she could 

once overcome bv her own strength of will. 

She should be encouraged and stimulated by cheerful society. 

and pleasant intercourse with a few friends. Her thoughts should 

not be introverted. She should not be permit- 
Diversion, in- mi 1 
ted to brood over such reflections as will make 

her nervous and wretched, but should become interested in the 
welfare and happiness of others ; for this is the line of thought 
that henceforth must engage her attention. 

Especially should you guard against the development of any 
disease to which she is predisposed. If she is liable to hemor- 
rhagic attacks from plethora, let her diet be 
P red U iJpostt g ions 5t heredkan " P iain an d unstimulatiiig, her habits as active as 
possible within the limits of prudence, and give 
her such remedies (according to their specific indications) as aco- 
nite, belladonna, veratrum vir., gelseminum, bryonia, or ipecacu- 



ON THE DISEASES OF WOMEN. 507 

anha. If, however, the haemorrhage is passive, and the result of 
an anaemic or vitiated habit, you may consult 

For the haemorrhage. . .,,. 

the merits of nitric acid, china, arsenicum alb., 
secale cor., sabina, crocus, trillium, erechthites, pulsatilla, ferrum 
met., and carbo vegetabilis. Cool acidulated drinks ought always 
to be preferred in this class of cases. Tea. and coffee should be 
interdicted, and so, also, should very active or violent exercise. 

Next to this tendency to haemorrhage, which is always alarm- 
ing and frequently dangerous, especially at this time of life, the 
possibility that the patient may pass almost 
ruhisis he tendency t0 insidiously ^ into a decline from tuberculosis 
in some of its forms, renders it necessary to 
antidote this predisposition whenever it exists. For this pur- 
pose certain precautionary measures are requisite. A limited 
amount of exposure is not necessarily harmful, but care should be 
taken that these patients incur no risks in this regard. They 
should not be suffered to take cold, to get the feet wet, to go out 
in a storm, to wear insufficient clothing, no matter how fashion- 
able, or to talk or to sing too much and too long at one time. 
They should keep in from the night air especially, and not be 
permitted to sit in the open air, as many women are in the habit 
of doing. Such a patient should not be removed from her old 
home into a new house, for example, in which the walls are not 
drjr. In brief, without being fussy, she should take unusual care of 
her health at this period, for a slight indiscretion, or an otherwise 
trifling cold might act as an exciting cause for the development 
of a latent disease that would soon carry her off. 

The remedies to be thought of in this connection are calcarea 
carb., calcarea phos., sanguinaria, phosphorus, stannum, mercurius 
jod., kali jod., kali brom., kali carb., hepar sulph., lachesis, sepia, 
lycopodium, nitric acid, ignatia, bryonia and silicea. The greatest 
possible care should be taken to recognize and to remedy the first 
symptoms of tuberculosis in a woman who is passing the critical 
period ; for if this is done there is little doubt that much trouble 
and suffering may be spared, and her life prolonged. 

The symptoms of coincident digestive disorders may be treated 
upon specific indications, always giving pref- 

For the digestive disorders. 

erence, however, when possible, to those reme- 
dies that have a curative relation to the < operative, as well as 



508 LECTURES, CLINICAL AND DIDACTIC, 

to the alimentary function. Nux vomica, colocynth, arsenicum 
alb., mercurius, pulsatilla, natrum mur., bryonia, calcarea carb., 
cocculus, veratrum alb. and veratrum vir., chamomilla, sulphur 
and belladonna belong to this class. The diet should be regulated 
with the greatest care. 

The wonderful influence of aconite over most of the derange- 
ments of the circulation at the climacteric, has long been known. 

It is an invaluable and almost indispensable 
circuLdo^ 150 ^" 5 ° f the remec ty. Other available remedies of this sort 

are veratrum viride, gelseminum, and bella- 
donna. They are not only indicated physiologically and patho- 
genetically in many cases, but the indication includes their special 
relation to disorders of the sexual system, more particularly to 
such as depend upon certain crises in the uterine and ovarian 
circulation. For the " flushes" and flashes of sudden heat, which 
constitute the most troublesome symptoms in milder cases, Dr. 
Madden recommends lachesis, either in the sixth or twelfth dilu- 
tion ; Dr. John F. Gray, sanguinaria ; and Dr. Trinks, sulphuric 
acid. You will find the indications for these and other remedies 
in Dr. Richard Hughes' excellent work on Therapeutics.* 

The nervous epiphenomena demand such remedies under 
almost the same identical indications, as would be prescribed for 

them if they were incident to the more com- 

For the nervous symptoms. 

mon menstrual disorders, as tor example, dys- 
menorrhea, amenorrhcea or menorrhagia. Belladonna, ignatia, 
hyoscyamus, coffea, chamomilla, moschus, pulsatilla, caulophyl- 
lin, macrotin and senecin, are most freely indicated. 

And so likewise of diseases of the generative organs that are 
incident to the critical period. The rules which I have so fre- 
quently repeated with reference to their medi- 
For the disorders of the CSL \ an( i sur pical management should be carried 

generative system. o & 

out in practice with even more than ordinary 
care and skill. Whatever can possibly interfere with the 
structural changes which result in the atrophy of the ovaries and 
the uterus, as a part of the critical process, should be removed. 
For these structural changes, brought about through fatty meta- 
morphosis, really pertain to the period through which the patient 

* A Manual of Therapeutics, by Richard Hughes, L.R.C.P. Ed., etc., etc., N. Y. 
1869, page 455. 



ON THE DISEASES OF WOMEN. 509 

is passing, quite as decidedly as the cessation of the flow itself. 
Since it might therefore interrupt this retrograde metamorphosis 
of the tissues if inflammation were established in them, you should 
see to it that such a contingency is averted ; or if it has already 
begun, to cure it and remove its consequences as speedily as 
possible. 

For the rheumatic and neuralgic complications, macrotin, rhus 
For rheumatism and neu- tox., atropine, the valerianate of zinc, mercurius, 
raIgia " and similar remedies will be required. 



.510 LECTURES, CLINICAL AND DIDACTIC, 



LECTURE XXX. 



SPINAL IRRITATION— NOTALGIA — " BACK- ACHE." 

Gentlemen : 

Some of the more advanced members of the class have fre- 
quently consulted me with regard to the treatment of spinal irri- 
tation. This woman has suffered from that disease for many 
years, and her clinical history will doubtless interest you. 

Case. — Mrs. M., aged fifty, enjoyed excellent health until her 
eleventh year. At that time, while running at play, she fell and 
struck the back of her neck against the corner of a table. The 
blow was upon the most prominent of the lower cervical vertebrae, 
(vertebra prominens). In consequence of this injury she was for 
six weeks very ill in bed, and so extremely weak and sensitive 
that they had to move her on a sheet. Several months elapsed 
before she could wear a dress. She finally got around again, 
but for several years her physicians did her but little good, and 
none of them referred her poor health to the injury that she 

had received. Finally, another physician, Dr. , while visiting 

her mother one day, touched the spot where the blow was received 
upon the neck, and she suddenly fainted away. Then followed a 
thorough course of blisters, with tartar emetic dressings, cups, 
leeches, and four years of barbarous treatment, which to think of, 
makes her "shudder to this day." With this treatment, there 
was much sloughing of flesh from the back, which is all scarred up 
now. It was a regular field-day when these sores were dressed. 
She cried, her mother cried, and all hands cried, but they could 
do no better, and she facetiously says, "it was equally impossible 
to do anything worse." In consequence of this injury, the left 
foot and limb were changed, the heel being drawn up as in a form 
of club-foot (pes equinus), in which position it remains. 

She did not menstruate until she had reached her eighteenth 
year, and then only once. She "never saw anything again" until 
after she was nineteen years old. From the time that menstrua- 
tion was really established, she began to improve, and kept toler- 



ON THE DISEASES OF WOMEN. 511 

ably well. At twenty-two she was married, and for eighteen 
months more her health remained pretty good. Then she skipped 
one month, and was supposed to be pregnant. At the eighth week 
she began to flow excessively. The haemorrhage continued, better 
and then very much worse, without interruption for two months 
more. Despite this flooding, her size increased until she measured 
one and one-quarter yards (forty-five inches) around the body 
over the abdomen. She was said by the physicians to be four 
months advanced in pregnancy. 

The flooding reduced her to death's door, and was not relieved 
until labor pains came on and continued severely enough to expel 
an enormous mass, which proved to be hydatids. With this mass 
many gallons of water were also discharged. The mass consisted 
of small bodies, which " varied from the size of a pea to that of a 
walnut, and which were strung together like grapes upon a stem." 

Two months elapsed before she could sit up. The lower limbs 
became powerless, and remained as if paralyzed for many weeks. 
In a little while the most severe and agonizing headaches com- 
menced. These recurred frequently, and kept her ill the whole 
summer. They were excruciating, and so severe that "it seemed 
as if she would go crazy with them." 

In eighteen months more her first child, a son, was born. In 
two years from his birth she had another child, which did not live 
but a year ; and in five years her third and last child, a daughter, 
was born. In every instance pregnancy and labor were normal 
in all respects. The labor was very severe, averaging about 
twenty-four hours, and the children were large. Her first and 
third children are still living. 

When she had been married thirteen years, she received a 
second injury. While on her way to church, and walking on an 
icy place doAvn hill, her feet slipped from under her and she fell. 
She thought of her back and neck, and " tried to save them." 
For this reason she struck upon her right elbow and her head 
was twisted backwards. She was lifted upright, and, with a 
woman's courage, walked home again. When she got up her 
head was fixed backwards, the muscles of the neck were rigid 
and spasmodically contracted, so that she could not turn the head 
or straighten it without taking hold, as she did, with her hands 
upon either side, and forcibly bringing it into position. When it 
turned, "something cracked as if a bone had suddenly gone into 
place." To this day she can not look up to the ceiling without 
supporting her head from behind with her hands. 

In consequence of this second accident she was kept in bed for 
about three months. The head could not be moved except by 
others, or rather excepting by her husband and one lady friend. 
This had to be done most carefully else it brought on paroxsysms 



512 LECTURES, CLINICAL AND DIDACTIC, 

of screaming, and agony that was almost unbearable. The head- 
ache returned, but in a different form. The first symptom of an 
attack was a feeling "as hot as fire almost," in a spot on the top 
of the head. If the husband began early and promptly when this 
burning commenced, to rub first over the sj:>ot and then to follow 
along down the body and extremities, the pain in the head would 
vanish. 

From that time until now, the region of the spine, for the space 
of nearlv an inch on either side, and running from the base of the 
skull to the last dorsal vertebra, has been so exquisitely tender 
that the weight of a feather brush would excite the keenest suf- 
fering. Even if one should point the finger towards the back it 
would make her "scringe." 

The lower part of the spine has remained perfectly well. In no 
sickness that she has ever had, so her husband says, has her mind 
seemed to be affected in the least. She has frequently been un- 
conscious and oblivious to passing events, but never in the least 
delirious or " out of her head." 

Before the birth of her last child, and for a short time only, she 
had some pain with menstruation. With this exception, she has 
never had dysmenorrhoea, or indeed any " female weakness " of 
airy kind. The spine is not as straight as it should be, but is 
curved posteriorly at a point midway between the shoulders. She 
can lie best upon her back, and could do so during all her sick- 
ness ; but, on account of pulling sensations in the opposite direc- 
tion, cannot lie upon either side. At times the head has felt very 
heavy, as if the shoulders could not sustain it, and as if it pushed 
directly downwards toward the body. It is impossible for her to 
sit upright without something to lean her head against. She can 
use her hands from the wrists automatically, providing her head 
and body are snugly fixed and padded, and there is no necessity 
for moving them. 

Beside the experiences in falling she has incurred other risks, 
among which was the swallowing of a tea-spoonful of the strong 
tincture of iodine, which a druggist's clerk had put up for Indian 
hemp ! Opium throws her into violent, frightful spasms, which 
last for days. She once suffered severely in this manner from 
taking a small quantity of this drug contained in a cough mixture. 
She cannot bear either very cold or very warm weather. Her 
worst attacks of prostration always occur in the winter and spring, 
generally in the months of February and March. 

The menstruation is becoming scantier, the flow is very debili- 
tating and very irregular. As she approaches the climacteric her 
general health is some wb at improved. 

Here is a case that would puzzle a clairvoyant. A spinal in- 
jury of a very serious nature is received at the impressible age of 



ON THE DISEASES OF WOMEN. 513 

eleven years. Its effect is to delay the establishment of the 
menstrual function. While the system is suffer- 
mg, not only from the traumatic lesion of the 
spinal nerves and muscles, but also from retarded puberty, she is 
placed under such treatment as would undermine and ruin the 
health of the strongest person. This voluntary martyrdom was 
continued for four long years. And yet she lived. At eighteen, 
when she had discontinued these barbarities, Nature renewed the 
attempt to establish the catamenia. The flow came once, but was 
not repeated for more than a year. After her marriage she be- 
came pregnant as she supposed, and the doctors insisted. Then 
after two months of flooding on her part, and of blundering on 
theirs, she is finally rid of a hydatid mass. Months elapsed and 
she barely survived. Then followed the birth of her three 
children. 

After thirteen years of married life she sustained the second in- 
jury, while on her way to church. (Perhaps it has never oc- 
curred to you that the men are almost never injured on their way 
to church.) Then the fearful suffering with the crampings in 
the muscles of the neck, the hypersesthesia of the superior spinal 
region, the headache, and the confinement in bed for several 
months. And, finally, the incidental vicissitudes and experiences 
so common to the female portion of humanity. This is but an 
outline sketch of thirty-nine years' experience on the part of this 
good woman. 

Causes. — Spinal irritation, as it is styled for the lack of a bet- 
ter name, most frequently arises from a traumatic injury, as, for 
instance, from a direct blow, or a fall upon 

Traumatic causes. 

some portion of the spinal column, or from a 
railway jar, or contusion. Of course men and women are alike 
subject to such accidents. But in women, who are more deli- 
cately organized, whose spinal muscles and 
predrs U ponen?. rganization a nerves are softer and more susceptible of injury, 
the first shock is more severe, and its secondary 
effects are more lasting and permanent. Add to this the peculiar 
impressibility of her general nervous system, in many cases amount- 
ing to a decided hysterical predisposition ; and the perturbing influ- 
ences of the crises through which she is always passing, or is about 
to pass, and we find there are especial reasons why she should 

33 



514 LECTURES, CLINICAL AND DIDACTIC, 

suffer more severely, and why such mishaps are more difficult of 
cure in her case than in men. 

The full significance of this idea is not apparent at first. Not 

only does it concern the fact that women are especially prone to 

this kind of martyrdom, but that a large meas- 

Practical inference. 

ure of their consequent suffering and mal-treat- 
ment is due to ignorance thereof. What a woman wants more 
than anything else when she is ill, is sympathy. And if her dis- 
ease is largely nervous, there is still greater need for this kind of 
universal emollient. But her family and friends are usually the 
last to realize how a slight fall, blow or shock, can so completely 
unhinge and demoralize her physically. They talk about resolu- 
tion and will on her part, and insist that she shall get up and go 
around, make some effort to throw off this incubus, and develop 
strength by the use of it. As a rule, the stronger they are, and 
the more muscular, the less their sympathy with this class of 
patients. This, of course, reacts upon the victim, and she can 
not accomplish what might be possible under different circum- 
stances. 

A similar misjudgment on the part of the physician may lead 
him to adopt such a means of treatment and of exercise as shall 

only add fuel to the flame. This happened in 

A common error. _ 

the case of Mrs. M. vv hue her nervous sym- 
pathies and susceptibilities were at their utmost tension, she was 
put upon the rack and tortured afresh. Her physician made no 
allowance for sexual impressibility and excitability, and hence the 
means employed were fitted to increase her suffering rather than 
to alleviate it. 

There can be no doubt that the doctor did the best that he 
could "with the light he had;" but it was the dark lantern of 
empiricism that he carried. He evidently mistook the case for 
one of spinal meningitis with effusion. But in this he was in 
error ; for whatever direct injury of the meninges may have fol- 
lowed the first fall, received some years before, the symptoms 
showed clearly enough that dropsy of the cord was not the real 
cause of her illness at the time she fainted from pressure upon 
the spinous process of the cervical vertebra. If any considerable 
effusion had existed and continued for so long a time, there must 
have been chronic and complete paralysis. 



ON THE DISEASES OF WOMEN. 515 

The very fact that puberty was arrested, without any intra- 
pelvic lesion, and that menstruation came on spontaneously when 
the treatment was suspended, shows that the 
disorder was mainly, if not altogether, of a 
nervous character. And whatever had a tendency more and 
more to derange her nervous system could only produce further 
irritation, perturbation and unrest. The marvel is that she sur- 
vived such unskillful and harmful treatment at all. 

Other causes of spinal irritation are strains, as from lifting, or 

jumping, lying, sitting or standing habitually in such a posture as 

to keep the spinal muscles on the stretch, and 

Exciting causes. 

thus to weaken and paralyze them. Rheuma- 
tism and neuralgia being predisponents of this disease, persons 
who have either of them are more or less decidedly susceptible 
to changes in the weather. For this reason, among others, as 
with our patient, extremes of heat and cold, and more especially 
of dryness and moisture, influence it greatly. The jar of travel 
by rail, in a rough carriage, or upon horseback, may induce it. 
And so, also, of tight lacing, the wearing of high-heeled shoes, 
and of articles of dress which are fastened at the waist and not 
hung upon the shoulders. 

Symptoms. — The symptoms are almost endless in their variety. 
If the disease has been caused by direct traumatic injury of the 
spine, the most severe pain will be located there, and we may 
accordingly find the suffering referred either to the lumbo-sacral, 
the dorsal, or the cervical region. 

If it is in the sacral region the pain will be less acute than 
when it is higher up along the vertebral column. It will be dull, 
aching and heavy in character, with complaint 
re|io°n mInjuryinthesacral °^ g reat weariness, exhaustion, and perhaps of 
numbness also. The patient wishes something 
to be pressed "into the hollow of her back," or to have her hips 
rest firmly upon something for support. She often stuffs a pillow 
or her shawl, or something of that kind, beneath her, or behind 
her, to rest her back and to give her ease. These pains are often 
accompanied by intra-pelvic pains, bearing down and distress, as 
if the womb were displaced. Indeed, they are often wrongly 
attributed to some slight and temporary deviation of the womb, 
and the attempt is made to cure them by pessaries, injections, etc. 



51G LECTURES, CLINICAL AND DIDACTIC, 

When the results of the injury, or the lesion, if there is one, 
are located in the dorsal region, the pain is more acute, with super- 
sensitiveness of the skin over the spinous pro- 

From injury in the dorsal cesses f the dorsal vertebras. Sometimes these 

region. 

processes are exquisitely tender to the touch. 
Direct pressure upon them, although it may be slight, may cause 
her to fall, to faint, to vomit, or to shriek as if she had been shot. 
I have seen two cases in which the pain produced in this way was 
compared to that from stabbing with a very sharp knife. The 
dorsal vertebras are most frequently affected. 

If the blow has been received, or the injury done to the spine, 
in the cervical region, the pain and soreness will vary according 
to circumstances. The suffering is apt to be 
viSore ion Uryin the cer ~ verv severe. Sometimes the arms become pow- 
erless from injury of the nerves which consti- 
tute the brachial plexus. Other branches of the cervical nerves 
being injured by the blow or the shock, the muscles of the back 
part of the neck are more or less implicated. These muscles, 
which you know are very numerous, including the splenitis colli, 
splenius capitis, cervicalis ascendens, transversalis colli, the tra- 
chelo- and sterno-mastoid, complexus, spinalis cervicis, trapezius 
and the obliquus superioris, are those which were spasmodically 
affected in the case of our patient, It was the painful cramp or 
contraction of these muscles that caused her head to be almost as 
immovably fixed as it is in torticollis, or wry-neck. Pressure upon 
the tender cervical vertebra may even stop the pulse at the wrist. 
When the symptoms are produced by other than mechanical 
causes, they are usually less intense but more erratic in their 
nature. The spinal tenderness is more diffuse. 

From incidental causes. . . 

It may be located in any portion 01 the back 
from the occiput to the point of the coccyx. Light pressure on 
the spinous processes of the tender vertebras produces consider- 
able pain, while firm pressure may be borne without flinching. 
This shows its neuralgic character. 

Now, from what I have said you will infer that the causes of 

spinal irritation act either centrically or ec- 
trk action?"'" and eccen ~ centrically. In the former case a mechanical 

injury is done to some portion of the vertebral 
column. The shock is felt by the spinal nerves, and the muscles 



ON THE DISEASES OF WOMEN. i'Al 

participate more or less in the painful result. In the eccentric 
variety, however, the cause is more remotely applied. The irri- 
tant is at work at the incident nerves in their distribution to some 
muscle or organ, and, in a reflex way, the spinal center may be- 
come implicated even to the extent of producing absolute organic 
disease of the medulla, or of its enveloping membranes. The pain 
and trouble may become localized, but the irritation caused in 
these nerves is more apt to be reflected from the cord again to some 
particular organ or apparatus, as, for example, to the stomach or the 
bowels, to the bronchi and the lungs, to the heart, the head, or 
the liver. 

It is in this manner that utero-meningeal disorders originate 
and are perpetuated. There are undoubtedly many cases of 
spinal irritation that are in no way connected 
utlSne al dSase ion and witn Serine disease. And there are other 
cases in which, for sexual reasons, and on 
account of the perturbing influence of the menstrual molimen, or 
of maternal contingencies, the womb becomes indirectly and sec- 
ondarily implicated. But there are other cases also in which the 
uterus has been the prime factor in this morbid process ; cases in 
which the spinal nerves and the medulla itself have become de- 
ranged and diseased in consequence of some pre-existing uterine 
lesion. For this reason there are few confirmed examples of 
" irritable uterus," in which these two affections do not co-exist. 
Moreover, most of the fugitive, peculiar, inexplicable local 
pains, burning and suffering that are incident to confirmed dis- 
eases and deviations of the womb, arise from 

Reflex symptoms. . ... -,.-,. -, 

uterine irritation which is conveyed by the 
sensitive nerve filaments to the cord and then reflected to these 
different points. It is thus that the infra-mammary pain is pro- 
duced. You remember that Dr. Simpson said this pain was as 
characteristic of uterine disease as the pain in the point of the 
shoulder is of hepatic disorder. We may refer the occipital 
headache of menstruation to a similar cause. The point which 
I wish to make is this, that the continued application of this irri- 
tant, brought from the suffering part to the sentient center, in the 
person of delicate, nervous women, is almost certain to cause a 
greater or less degree of spinal irritation. 

And what is true of the uterus is also true of the ovaries. The 



518 LECTURES, CLINICAL AND DIDACTIC, 

most troublesome cases of spinal irritation that I have ever treated 
originated in ovarialgia. The contingencies that 

From ovarian implication. , , , 

beset ovulation even when the periods are regu- 
lar : that may derange the innervation of these organs at puberty 
and the climacteric ; that may result from intemperate coitus and 
similar causes, are indirectly responsible for a large proportion of 
cases of what are termed spinal irritation. There maybe cases in 
which the converse is true, and wherein the ovarian disease is sec- 
ondary upon the spinal lesion. Indeed, it is sometimes extremely 
difficult to decide between the cause and its effect, and to say 
positively whether the ovarian lesion is idiopathic, or vice 
versa. 

As a rule, however, I think you will find that the other coinci- 
dent disorders which sometimes attend upon spinal irritation are 

almost always secondary. Such are the dis- 

Secondary diseases. „ . T , . , 

eases 01 the respiratory system, it is seldom 
that aphonia, spasm of the glottis, dyspnoea, or a violent nervous 
cough, in these cases is not directly referable to the spinal lesion. 
So also of functional troubles of the heart, and of the digestive 
system. We look to the spinal center for their cause, and hope 
to relieve them by its cure or removal. 

Diagnosis — Providing it has been caused by direct injury, and 
is therefore traumatic, the diagnosis of spinal irritation is not very 

difficult. This is true, no matter how long a 

In post-traumatic cases. . . .... 

period may have elapsed since the injury was 
sustained. It holds in Mrs. M.'s case, for example, although 
thirty-nine years have passed since the date of the accident. For 
this reason you should take especial pains to enquire whether 
such a patient has ever fallen, or received a blow upon any part 
of her back. It is possible that so long a time has elapsed since 
the accident occurred, or that the mischief itself was attended by 
so little pain and immediate illness, that it may have been for- 
gotten. She may have tumbled down stairs, fallen upon the ice, 
from her horse while riding, or from a chair upon which she was 
about to sit, and hurt her back long ago, but because she thought 
it a trivial affair at the time,, may forget to mention the circum- 
stance unless you enquire for it. 

Or it may happen that on account of mechanical injury to the 
coccyx during labor, a similar train of symptoms may have 



ON THE DISEASES OF WOMEN. 519 

been induced. In a word, whenever you can refer the lesion to 
a traumatic injury, however complicated the 

May arise from coccyodynia. . 

attendant symptoms, or trivial and remote the 
date of the accident, the original idiopathic disease will not be 
difficult of recognition. 

But, under different circumstances, the case is very different. 
When neither the patient nor her friends can recall such a misfor- 
tune, and there is no reason to believe that any 
diSrS^ 65 in the way ° f portion of the vertebral column has ever been 
directly injured, it will not be so easy to decide 
the question. The tenderness of some portion of the spine upon 
contact and pressure, more particularly if it is constant, or habitual 
in certain positions of the body, is quite characteristic. If this 
tenderness is aggravated by the return or interruption of the 
menses, by coitus, by emotional states, or by sudden displace- 
ments of the womb, there is manifest spinal irritation of a reflex 
nature. Sometimes this exacerbation of pain and super-sensitive- 
ness in the spine alternates with the sexual infirmity or excitement, 
and this fact will help you to differentiate it properly. In very 
rare cases there is a cutaneous ansesthesia, which is allied to the 
pseudo-narcotism of hysteria, and which is almost invariably due 
to uterine or ovarian disease. 

Spinal irritation should not, and need not be confounded with 
inflammation of the spinal cord or of its membranes. Its advent 
is not characterized by a chill, rigors or fever. 
tio^ i of"he S cord?e i t n c f ' amma " The pain is circumscribed in extent, erratic in 
character, and, in general, is worse upon slight, 
than upon steady or firm pressure. There is less dread of motion, 
and, unless in case of traumatic myalgia, more ability to move 
about than in real meningitis and myelitis. In the adult, menin- 
gitis is almost always either traumatic or epidemic. If paralysis 
occurs in spinal irritation, it is self-limited and not permanent, as 
it is apt to be in consequence of inflammation with serous effusion 
into the spinal canal. 

This disease may be distinguished from true neuralgia by the 
cliffuseness of the pain which does not follow the track of any 
nerve or nerves, but is characterized, so far as it extends, by a 
general cutaneous tenderness. The reflex irritability is exagger- 
ated, and sometimes intensely so. Spinal irritation bears a pretty 



520 LECTUBES, CLESTCAL AST) DIDACTIC, 

close resemblance to neuralgia, however, in such cases as we have 
had under review this morning. For where the cervical vertebrae 
are injured, it presents many of the symptoms of cervico-brachial 
neuralgia. This is especially true in highly neurotic patients. 

Prognosis. — The prognosis will depend upon the location, 
nature, extent, severity, and duration of the spinal lesion, the age 
of the patient, her peculiar nervous impressibility, and the more 
or less serious derangement of the menstrual function. The dan- 
ger is not usually proportionate to the degree of suffering. Coin- 
cident disorders of respiration may be more grave in character 
than such as implicate digestion. The nervous symptoms are 
usually more alarming than serious, although it is possible that 
permanent paralysis of some of the voluntary muscles may fol- 
low. In some cases there is a form of hysterical mania that is 
quite unmanageable by the ordinary means, which is, however, 
likely to terminate of itself, providing too much is not done in the 
way of treatment. 

In case the irritation has been caused and maintained by a 
lesion of the generative organs, the possibility of cure will depend 
upon one of two things ; (1), the curability of the uterine or of 
the ovarian disease, whatever it may be, and (2), our ability to 
remove such sequelae as may remain when the antecedent affection 
has been remedied. Patients with spinal irritation frequently 
recover when the climacteric has passed. 

Treatment. — These are the patients who travel from one physi- 
cian to another. By the time you have them fairly in hand you 
will find that they are experienced itinerants. 
They have run the whole gamut of the profes- 
sional possibilities, and. at last, are persuaded that, if you can not 
benefit them, nobody can. But, in a short time, unless you are very 
skillful in treating them, or successful in satisfying them that you 
do really understand the case and expect to cure them, they will 
be adrift again. 

If from any cause the symptoms of spinal irritation are devel- 
oped, as they were in this case, at a time when the menstrual 
function is about to be established, or when the 
^Guaid the menstrual fane- changes that are incident to puberty have 
already begun, you should take the greatest 
possible care to do nothing that can interrupt this process, or pre- 



ON THE DISEASES OF WOMEN. 521 

vent its accomplishment. Your aim should be to remove all obsta- 
cles thereto, and so to regulate the operations of the nervous 
system as to favor and assist Nature in her critical effort. For it 
is manifest that if puberty is not delayed, and the catamenia 
appear as they should, the nervous and other functions can not 
be in a very bad condition. 

If the symptoms of spinal irritation appear when the menses 

have been suppressed, as after pregnancy, lying-in and lactation, 

or from amenorrhea, a similar indication will 

in amenorrhea and at ex i s t. And if they come on with the climac- 

tne climacteric. « 

teric period, you will bear in mind what I said 
in my last lecture concerning their treatment under these circum- 
stances. 

Incidentally, whatever disease may drain the patient's strength 

or exhaust her energies, should be remedied as speedily as possible. 

A quarter of a century ago, when this poor 

Remove any dangerous woman suffered for two consecutive months 

condition. 

with uterine haemorrhage that was due to the 
presence of a hydatid mass in utero, there may have been some 
excuse for a lack of promptness in emptying the womb and stop- 
ping the flow. For the sponge-tent was unknown, and physicians 
had almost as great a dread of manipulating or operating upon the 
uterine cervix as surgeons had of opening the cavity of the peri- 
toneum. But now such a haemorrhage should not be permitted. 
The neck of the womb could be readily dilated and the foreign 
body removed. 

In order to counteract the peculiar impressibility of } r our female 

patients, and thereby to put them in a condition that is favorable 

to the cure of spinal irritation, you will need 

Tact and sympathy. 

to exercise a great deal 01 tact and a large 
measure of sympathy and discretion. Rough treatment may 
sometimes be tolerated in other cases (although it is inexcusable), 
but in this disease it will not be borne. The patient's perceptions 
are too acute, and she is too susceptible and sensitive to be treated 
in such a way. Your manner should be kindly, your words fitly 
chosen, your tone sympathizing, and your faith in her desire to 
get well, and not to deceive you, unbounded. If you are fully 
impressed with the tenderness and delicacy of her organization on 
the one hand, and with the irritable, excitable and wretched stale 



522 LECTURES, CLINICAL AND DIDACTIC, 

of her nervous s}*stem on the other, 3-011 will never be guilty of 
adopting such a mode of treatment as must necessarily make her 
worse instead of better. 

If the attack originated in a strain, shock, blow, or fall, 

although years may have passed since the injury was sustained, 

arnica, rhus tox., calendula, or the hypericum 

For the effects of the per f w in be indicated. I have great confi- 

spinal injury. -L ' ^ 

dence in the latter remed} r given internally and 
applied locally at the same time for traumatic injuries of the spine 
and its membranes. The other medicines named may also be used 
both constitutionally and externally. 

For rheumatic and neuralgic complications the most prominent 

remedy in many cases is macrotin, after which there are rhus tox., 

bryonia, spigelia, belladonna, atropine, aconite, 

For rheumatic and neu- veratrum alb., veratrum vir., colocynth, lachesis, 

ralgic symptoms. J 

caulophyllum, nux vomica, colchicum, and gel- 
seminum, with the leading indications for which you are already 
familiar. 

Whatever uterine or ovarian diseases have been sufficient to caus \ 

or to complicate the spinal lesion, should first be treated as if they 

existed separately and idiopathically. But 

For the uterine and ova- w ] ien these are removed or cured, such spinal 

nan symptoms. -L 

and nervous sequela? as remain may be treated 
more directly and specifically. Uterine deviations, cervicitis, 
hypertrophy, and ulceration of the cervix uteri and hysteralgia 
are the more frequent of these affections, which have the first 
claim on our professional attention. To these may be added sub- 
acute and chronic ovaritis, and ovarian neuralgia. 

The respiratory, digestive, hepatic and general nervous derange- 
ments which are secondary upon the spinal trouble, will usually 

yield to treatment that is addressed to the cure 

For contingent disorders. 1 1 

ot the lesion upon which they are dependent 
for a cause. The symptoms must be carefully studied and the 
remedy affiliated properly, else there will be but a poor prospect 
of success. 

Local adjuvants are sometimes of the greatest possiolp service 

in the treatment of this troublesome com- 

Local treatment. 

plaint. They are not only grateful and useful 
on account of the relief which they afford, but do really assist in 



OX THE DISEASES OF WOMEN. 523 

the cure. I suppose that their modus operandi is by excluding 
the presence and pressure of the atmosphere upon the tender sur- 
face along the spine. My own preference for these local expedi- 
ents has been based upon the following indications : 

If the muscles of the back or of the neck are cramped and very 

painful, I direct that the surface shall be thoroughly anointed 

w T ith camphorated oil. This may be gently 

For painful cramping, etc. . tit 

rubbed over the painful part, or applied by 
means of flannel compresses. The oil soothes and softens, and the 
camphor relaxes the muscular spasm. Bathing with spirits of 
camphor is less efficacious, because both the camphor and the 
alcohol evaporate so quickly. 

Where there is less pain and more diffuse tenderness, it gives 
great relief to coat the surface with the oleaginous collodion. 

If the disease has resulted from a mechanical cause, you will 

not forget the local use of arnica, hypericum, calendula and 

hamamelis. I believe these topical applications 

Topical expedients. .,.,. .,, 

have the best effect, in this disease especially, 
when they are diluted in and applied by means of hot, instead of 
cool or cold water. In mild cases, a porous plaster will sometimes 
afford relief. Dry cupping, and the exhaustion of the air by 
means of cups to which the air-pump is attached, affords a useful 
expedient in some cases. But sinapisms, blisters, pustulation by 
croton oil or tartar emetic, and issues and setons of all kinds are 
harmful and unnecessary. 

The spine should be insulated as it were, by a layer of cotton 
batting, or of oiled silk, worn next the skin. The cotton may be 

sewed into the clothing and kept constantly 

Domestic expedients. -,.-,-, i tt it ir» 

applied, day and night. It should extend from 
the neck throughout the whole length of the back. In many 
cases, more particularly in those who are predisposed to rheu- 
matism, the patient should wear a silk vest, or under-wrapper, to 
protect her from sudden vicissitudes of the weather, and from 
electrical changes. 

Sponging the back from above downwards with warm, or hot 
water, may help to remove the extreme sensitiveness of the integu- 
ment. It should be done verv carefully how- 

Available expedients. . p 1 ' 

ever, and, it possible, by a person who is m 
sympathy with the patient, and towards whom she has no feeling 



524 LECTURES, CLINICAL AND DIDACTIC, 

of antagonism. In chronic cases, with marked debility, salt-water 
spongings along the spine are sometimes very beneficial. In cer- 
tain cases, the shower-bath, electricity, and animal magnetism 
may also be useful. They should, however, be administered with 
care and discrimination, else they may only serve to increase the 
difficulty. The electrical bath answers as an available tonic, 
when the general strength is very much reduced, and the patient's 
nervous system needs a ready means of support of some kind. 

An ancient writer says: "There is one special phase, however, 
of spinal irritation which is very amenable to a direct treatment, 
viz. : cutaneous and mucous tenderness. When- 
ever the ' hypersesthetic ' part is within reach, 
so that we can apply Faradization, we can almost certainly eradi- 
cate the morbid sensibility very quickly. The secondary current 
of an electro-magnetic or volta-electric induction apparatus is to 
be employed; the conductors should be of dry metal, and the 
negative one, which is to be applied to the painful surface, should 
be in the form of the wire-brush. The positive pole is to be 
placed on some indifferent spot, and the negative is to be stroked 
briskly backward or forward over the sensitive skin, a pretty 
strong current being employed. The process is painful, so much 
so that it will often be advisable, with delicate patients, either to 
administer chloroform or to inject morphia subcutaneously before 
the Faradization. A very few daily sittings of four or five 
minutes length, will generally remove the morbid tenderness com- 
pletely. When the tender part is within one of the cavities, as 
the rectum, bladder, vagina, or pharynx, we must of course use a 
solid negative conductor of appropriate form, and must content 
ourselves with applying it to one point after another of the sensi- 
tive surface.'' * 



HYSTERICAL HEMIPLEGIA. 

cV{N?.~Mary J , aged 29, seamstress, unmarried, had been 

in poor health for more than a month, complaining of headache, 
fatigue, debility, drowsiness, loss of memory, and disinclination 
to work. Two weeks ago she was suddenly seized during the 
night with a violent fit of hysteria. The spasms of the voluntary 
muscles were very severe. She talked foolishly of her little 

* Neuralgia and the Diseases that Resemble it. By Francis E. Anstie, M.D., etc.. 
New Yoik. D. Appleton & Co., 1872, p. 299. 



ON THE DISEASES OF WOMEN. 525 

love affairs, of church matters, and upon all kinds of topics. 
In about half an hour the paroxysm passed off with alter- 
nate laughing and crying, and finally with the escape of a large 
quantity of colorless urine. The next morning her right 
arm and leg were paralyzed. The muscles were relaxed. She 
could move the leg a little, but only with the greatest effort. 
The arm was quite powerless. Her consciousness was complete, 
and had been from the subsidence of the fit. The face was not 
paralyzed, nor did the tongue turn to the right angle of the mouth 
when she protruded it ; her speech was unimpaired, but it was 
sometimes difficult for her to swallow. She complained of frontal 
headache and inability to sleep. The right pupil was considera- 
bly enlarged, but the left one remained unaltered. The bowels 
were obstinately constipated. 

The menstrual flow, which had begun only a few hours before 
the hysterical attack set in, was arrested, and did not return. 
She has been subject to amenorrhcea, and sometimes passes several 
months without any " show." She has frequently had hysteria in 
a mild form, but these paralytic symptoms are new, and have 
alarmed both herself and family very much. 

This case is apropos to the preceding one. It furnishes another 
illustration of the hysterical mimicry of which I have already 

spoken. One would say, at first thought, that 

it would be quite impossible for this or any 
other affection to imitate so grave a disease as hemiplegia. But 
here you see a case in which the right half of the body is power- 
less. This poor girl had to be carried into the amphitheatre, for 
she cannot stand alone. When she attempts to walk, the right 
limb, which seems a little stronger than it was at first, swings 
with a pendulum-like motion, directly forwards and backwards, 
but its abduction and adduction are impossible. You will observe 
that the arm hangs helpless by her side. 

There is an evident paralysis of the nerves of motion. Let us see 
if the nerves of sensation are in the same state. For these two forms 

of palsy have no necessary relation to each other. 

Observe that when I stuck the pin into her 
arm, to test this question, it was done without her knowledge. 
If I had told you in her hearing what I intended to do, and she 
had seen the point of the pin coming towards her, she would 
have imagined that she felt it, whether she really did so or not. 
We must be cautious in these little matters. I once introduced 
a sound into the female bladder, and on turning it about observed 



526 LECTURES, CLINICAL AND DIDACTIC, 

a clicking noise, which exactly resembled that caused by the 
striking of a metallic instrument against a calculus, which disease 
she was supposed to have. Having withdrawn the instrument, I 
was about to declare that my patient had stone 
in the bladder, when, upon turning its handle, 
I discovered that it had become loosened and gave forth precisely 
the same click that I had heard before. This shows the impor- 
tance of being always on our guard, lest we arrive at wrong con- 
clusions in diagnosis. 

Naturally enough you would like to know what variety of 

unilateral paralysis it is from which this patient is suffering. I 

have no doubt but that it is hysterical, and my 

Diagnosis. . 

judgment is based upon the following reasons. 

1. She is of the hysterical temperament. This peculiar constitution 

is as different from the apoplectic habit as the scrofulous cachexia 

is from the sanguineous temperament. The fact that she has 

been subject to hysteria before precludes the 

probability that her paralysis is due to effusion, 

either of blood or of serum, within the cerebro-spinal cavity. 

2. Hysterical attacks commence abruptly, and are not accom- 
panied by marked signs of congestion, fever, coma or constitu- 
tional disturbance. There are no lesions of the perceptive 
centers in hysteria, as there are in apoplexy, whether it be ner- 
vous, serons, or sanguineous. 

3. The relation of the menstrual arrest to the initiatory parox- 
ysm. A mere suppression of the menses in one of her slender 
form and delicate organization would not be likely to induce such 
a determination of blood to the head as to result in apoplexy, or 
such a disorder of the cerebral nutrition as, in the short space of 
a fortnight (more especially in one so young), to cause softening 
of the brain. In such subjects as this the menses are very apt to 
be scanty and irregular. Hysterical paralysis is more frequent at 
puberty and the change of life, when these particular crises influ- 
ence the general nervous system so decidedly, than at other 
times. 

4. The sweeping motion of the leg, and the absence of paraly- 
sis of the face and tongue, enable us to exclude the more ordinary 
forms of hemiplegia, and to identify the hysterical variety: 

Other signs are classed as diagnostic of this singular affection. 

o O o 



ON THE DISEASES OF WOMEN. 527 

Among them are the ability to move the palsied extremity under 
sudden and powerful emotional impulse. Such 

Other differential signs. . . 

a patient may sometimes be so shocked or start- 
led as to use the limb automatically, and without thinking of what 
she is doing. One of my neighbors, who had not walked a square 
for months, left her bed suddenly, the night of the great fire in 
this city, in October last, and marched three miles in order to 
save her life. 

If the patient feigns paralysis of the arm especially, you will 
observe that when she stoops forward she keeps it close to her 

side. In absolute paralysis of that member it 

Position of the arm. 

would be impossible lor her to do so, tor, hav- 
ing no voluntary control over it, it would fall forward when she 
stoops towards the floor. 

Another distinguishing peculiarity of the hysterical paralysis is 
that there is very little atrophy of the muscles of the affected part. 

If the arm or the leg, or both, are helpless and 

Absence of atrophy. ,-.... 

useless lor months, their size is not so apt to 
be diminished as in ordinary palsy. The limb does not become 
shrunken and attenuated, but remains as plump and fleshy as the 
sound one. 

In many cases, the hyterical fits recur from time to time, with 
or without choreic movements of the other voluntary muscles. 
Sometimes there is an incidental aphonia, and globus hystericus is 
the rule and not the exception. 

Hysterical hemiplegia is not a very common form of paralysis. 

Hysterical paraplegia is more frequently seen. In the former it 

is said that the left side is more apt to be affect- 
May occur in measles. i • i -r» • l -it 

ed than the right one. Being largely the result 
of emotional causes, there is no doubt that it may occur in men as 
well as in women. Indeed it is very probable that a large pro- 
portion of the cases of paralysis that are cured by itinerant pre- 
tenders through the "laying on of hands," animal magnetism, and 
every species of mummery, are hysterical, functional, emotional, 
circumstantial, self-limited, and not dependent upon any struc- 
tural lesion whatever. 

Unless the disease is complicated with some serious lesion, 
either of the brain or spinal cord, the prognosis is generally favor- 
able. It may require a long time to effect a cure, but the patient 



528 LECTURES, CLINICAL AND DIDACTIC, 

and persistent use of the proper means will ultimately succeed. 
In many cases the affection leaves as abruptly 

Prognosis. 1 

as the hysterical aphonia or meteonsm are apt 
to do. If the jDaralysis comes on during the climacteric, the more 
or less serious nature of the incidental disorders, and the condition 
of the general health will modify your judgment of its severity. 

Treatment. — The auxiliary treatment of this affection is very 
important. It includes the proper employment of friction, elec- 
tricity, animal magnetism, the movement cure, 
the health-lift, Faradization, bathing, and ex- 
ercise, both physical and mental. It prescribes fresh air, sun- 
light, change of scene, travel, pleasant and agreeable society, good, 
healthy, and nourishing food, and the careful use of stimulants. 
It orders the removal of whatever may cause her to become impa- 
tient and irritable, or that can in any way disturb her mental equi- 
librium. 

Ignatia, gelseminum, belladonna, secale cornutum, cuprum, 
plumbum, rhus tox., cocculus, causticum, barvta 

Internal remedies. ' _ . 

carb., caulophyllm, phosphorus, and zmcum me- 
tallicum, are the remedies most frequently indicated. 



ON THE DISEASES OF WOMEN. 529 



LECTURE XXXI 



fibroid tumors of the uterus. 

Gentlemen : 

A course of lectures on our specialty would be very incomplete 
without some remarks upon the clinical history and treatment of 
uterine fibroids. This is true not only because of the interest 
which attaches to neoplastic growths in general, but especially 
because those which are uterine are more readily diagnosticated 
and cured than they were a few years ago. 

These tumors which, according to various authors are found in 

from 20 to 40 per cent, of those women who are ill with uterine 

disease after their thirty-fifth year, are benign 

Relative frequency. 1 

and not malignant. JNor do they ever degen- 
erate into cancer, or any other form of malignant growth. This 
fact is interesting in a prognostic point of view, and also with 
respect to their cause and mode of development. 

I need not remind you that the fibrous and cellular structures 
of the uterine wall exist in a rudimentary state until they are 

especially developed in consequence of concep- 

Pathological anatomy. , . . _ . 

tion, or of the growth withm the uterine cavity 
of a foreign body of some kind. The possibility of this extraor- 
dinary increase necessitates such changes in the circulation to 
and through the organ as will supply sufficient nutritive material 
therefor. It is because the depth and dimensions of the uterus 
may be so much increased, in consequence of a physiological 
stimulus, that these fibroids are formed. In all essential particu- 
lars, their growth and development is identical with that which 
takes place in the muscular coat of the womb during pregnancy. 
The only difference is that in fibroids the actual increase in the 
substance of the uterus is circumscribed, instead of being general ; 
and that it is pathological and more or less permanent, instead of 

34 



530 LECTURES, CLINICAL AND DIDACTIC, 

being physiological and of limited duration, as it is in pregnane}'. 

Unless they have undergone some form of benign degeneration, 

fibroids are therefore homologous and not heterologous. There 

is indeed a new growth of tissue, but it is of 

Homologous growths. 

the nature 01 a local hypertrophy, and, except- 
ing in a mechanical way, is not foreign to the part affected. 
Sometimes these tumors consist exclusively of a prematurely de- 
veloped muscular fibre, constituting veritable myomata, but in 
most cases the connective tissue is also involved, and hence it has 
been customary to style them myo-fibromata. Microscopically 
considered, there is nothing distinctive in these growths, except- 
ing perhaps, that the arrangement of their fibres is more irregu- 
lar, wavy and tortuous than in the proper uterine tissue. 

These tumors are either single or multiple. There may be 
but one of them ; there have been as many as forty within and 
upon the same womb. They generally assume 
teSur? er ' weight and a rounded form at first, and afterwards change 
their shape, according to circumstances. They 
may remain sessile, but are more apt to become pedunculated. 
Their size varies from that of a marble to a man's head, or even 
larger. They may weigh an ounce, or as much as twenty, thirty, 
fifty, or even a hundred pounds. Their solidity varies with 
their location and vascularity, the rapidity of their growth, and 
their tendency to undergo cystic, carneous, calcareous, or fatty 
degeneration. The more strictly fibrous the tumor, the more suc- 
culent it is. 

There are three varieties of uterine fibroids which are named 
from their location with reference to the cavi- 
ties of the womb and of the abdomen, and also 
to the uterine wall. I will speak of them separately. 

I. SUB-MUCOUS FIBROIDS. 

As their name implies, these tumors are situated directly be- 
neath the endometrium, or lining membrane of the womb. They 
are really contained within the uterine cavity, 

Sessile or pedunculated. , t < i i • ■ , • 

and hence are frequently ctyled. mtra-uterme. 
Their mode of develormient appears to be as follows : From some 
cause, which may be known or unknown, the fibro-cellular tissue 



ON THE DISEASES OF WOMEN. 531 

of the uterus becomes thickened, and of increased vascularity at 
a particular point. This growth, nodule, or hypertrophy, con- 
tinues to increase in size, perhaps for months, or even for years, 
without any untoward symptoms. Being located in closer prox- 
imity with the mucous than with the peritoneal coat of the organ, 
it pushes in that direction, and finally invades the uterine cavity. 
Here it may continue to grow in all directions as a round tumor, 
with a broad base, which gradually fills the womb ; or it may be- 
come pear-shaped, and finally develop into a fibrous polyp, with a 
neck or stalk which is sufficiently long and slender to allow it to 
drop into the os internum, or even into the vagina. As in ova- 
rian tumors and polypi, the pedicle is the means of keeping up 
the vascular connection with the uterus. 

Symptoms. — The symptoms indicative of the presence of such 
a tumor are objective and subjective. The patient complains of 
a sense of weight and dragging down, intra-pelvic pains and dis- 
tress, lumbo-abdominal aching, vesical or rectal tenesmus, inabil- 
ity to walk without great dread of procidentia of the pelvic organs, 
uterine colic, pains in lying upon one side or the other, sick head- 
ache, nausea, morning sickness as in pregnancy, copious and 
sometimes very painful menstruation ; the catamenia are too fre- 
quent as well as menorrhagic ; weakness, prostration, constipation 
and unrest. Of course these symptoms vary in different cases, 
and also with the size and shape of the tumor or tumors. The 
larger the tumor the greater the coincident suffering. Pedicu- 
lated fibroids are, in general, more likely to excite strong uterine 
contractions than those which are sessile. Indeed, there is a 
theory that, in some cases, the force of the peristaltic contrac- 
tions of the womb, or the uterine tenesmus, is the cause of this 
particular form of the tumor, and that these bear a constant rela- 
tion to each other. My own observations confirm the truth of 
this theory. There are, however, some exceptions to the rule. 

The most alarming and constant of these symptoms is the 

haemorrhage which, however, is a menstrual flux. Seventy 

per cent, of infra-uterine fibroids are accom- 

The haemorrhage. 

panied by haemorrhage. The flow, which is 
very free, is usually, but not always painful, and very debilitating. 
If it has continued long, the patient becomes anaemic, bloodless, 
and perhaps dropsical also. It returns every fortnight, or three 



532 LECTURES, CLINICAL AND DIDACTIC, 

weeks ; she does not recover from one attack before another is 
upon her. It is astonishing how small a fibroid may serve to per- 
petuate such a haemorrhage. For it may happen that a little 
body of this sort, which is not larger than a grape, may cause as 
great a loss of blood as sometimes does the fragment of placenta 
which is left in the womb after an abortion. Leucorrhcea, serous 
discharges and obstructive dysmenorrhcea are often due to the 
presence of uterine fibroids. More rarel} r the tumor blocks up 
the outlet, and there is complete retention of the menses. 

Incidental symptoms of uterine deviation are always present. 
The larger the tumor the greater the displacement. Being at- 
tached more frequently to the posterior wall of 

Uterine displacements. 

the womb, retroversion and retroflexion are very 
common. If, however, as sometimes happens, the point of attach- 
ment is to the fundus, and the tumor is a very large one, the organ 
may be inverted. Anteversion, anteflexion and prolapsus are not 
infrequent. Latero-version, a state of things in which the body of 
the womb is forced towards one side of the pelvic basin, is some- 
times caused by the presence of an intra-uterine fibroid. 

Beside the morning sickness, anorexia and caprices of appetite, 
the development of the mammary glands, of the areola?, and of the 

abdomen, there are other signs simulating 

Changes in the cervix. 

those of pregnancy, that are caused by the 
growth of a fibroid in utero. The cervix is shortened, and may 
become flaccid and patulous. More frequently, however, after some 
months, it forms a ring which is resistant and sometimes very sen- 
sitive to the touch. Auscultation through the abdominal pari- 

etes (providing the tumor has passed above the 

The uterine souffle. . . , . , . m . 

pelvic brim) reveals the uterine souffle, which 
you remember was once regarded as a positive sign of pregnancy. 
In exceptional cases there is a singular tolerance of the pres- 
ence of these tumors. Some women cany them for }~ears and 

become so accustomed to them that they make 

Tolerance of the tumor. , 

very little if any complaint 01 them. It is onrv 
in consequence of the haemorrhage, or the pressure they occasion, 
that they are led to take measures for their removal. They do 
not always interfere with pregnancy, although they grow more 
rapidly in the gravid than in the non-gravid uterus. They some- 
times cause abortion. 



ON THE DISEASES OF WOMEN. 533 

These tumors, as they grow, lead to an enlargement of the 

uterus and an increased size of its cavity. Hence, if the organ is 

not quite filled with the fibroid, the sound will 

Increased size of the uterus. . „ 

pass quite readily, and perhaps farther thanyou 
would have supposed. For the depth of the uterus may be as 
great as it is at term. In order to get the best idea of the size, 
and the point and mode of attachment of the growth, you should 
select a flexible sound, which, will adapt itself to the contour of 
the tumor without force, and, therefore, without inducing pain 
or haemorrhage. 

As felt through the abdominal parietes, the outline of the 
tumor can usually be very well recognized. There is dullness on 
percussion over the whole anterior surface of 
the womb. It is not unusual for the patient to 
complain that one particular spot is and has always been painful 
and tender to the touch ; but there is no diffuse soreness. The 
uterus is hard and resistant to external palpation. 

These tumors, being invariably attached to the body and fun- 
dus of the womb, a vaginal examination by the touch is of little 
use unless the growth is large enough to be 
felt, or so to displace the uterus that it can be 
reached. In case the tumor is very large, the whole organ may 
be displaced upwards, above the brim of the pelvis and the 
"touch" reveal nothing. In some cases the 

Bi-manual examination. ..-,.-, 

"touch may be conjoined with pressure with 
the tips of the fingers of the free hand over the uterus and just 
above the pubes, as in Sims' bi-manual exploration. 

Causes. — The causes are not well known. That the growth of 
these tumors bears a certain relation to the menstrual function, 

and to that of procreation also, is evident from 

bearfn g s . truation and child ~ tne fact tnat tne y are most frequently devel- 
oped at a period when these functions are most 
active. But precisely what that relation is has not been deter- 
mined. In a certain class of cases it is probable that the fibroid is 
a sequel, or a consequence, of the incomplete involution, or fold- 
ing upon itself, of the uterus after delivery. It has happened 
that a clot has been found to form the nucleus of a uterine 
fibroid. 

Diagnosis. — The diagnosis is difficult. I have already told you 



534 LECTURES, CLINICAL AXD DIDACTIC, 

how to diagnosticate a case of intra-uterine fibroids from one of 
ovarian dropsy.* The hardness and mobility of 

From an ovarian cyst. 

the tumor ; the absence of fluctuation ; the 
depth of the womb, as shown oy the distance to which the sound 
will enter ; the co-existence of haemorrhage, which may be men- 
strual, but is often inter-periodic ; the pain and uterine tenesmus ; 
the uterine souffle in either groin ; the uterine displacement and 
leucorrhcea ; and the comparatively slow rate of the growth of 
:hese fibroids, are sufficiently characteristic. The occurrence of 
uterine fibroids and of ovarian dropsy are not very frequent in 
those who have never been pregnant. 

The incidental haemorrhage, with its tendency in most cases to 
return at or near the month with tolerable regularity ; the tardy 
and protracted growth of the tumor; the 
absence of quickening and of the foetal heart 
sounds ; the rounded outline and hardness of the tumor as felt 
through the abdominal walls : the patulous state of the os uteri ; 
and the persistent displacement of the womb, are so many signs 
which will help you to differentiate this variety of uterine fibroids 
from pregnancy. The altered and peculiar shape and consistence 
of the cervix in case of placenta praevia, would be as different 
from that which is proper to uterine fibroids, as it is from that of 
ordinary pregnancy. You should not forget that it is possible for 
a woman with any variety of uterine fibroid to become pregnant, 
although, in case of the intra-uterine variety especially, they sel- 
dom reach term without aborting. It is therefore best not to pass the 
sound in all cases indiscriminately, and without thought of the 
possible consequences. Perhaps, in a majority of cases the large 
fibroid becomes impacted in the pelvis and does not rise into the 
abdominal cavity, as the gravid uterus does, at or about the fourth 
month. 

In the case of uterine hydatids the abdominal tumor is larger, 
grows more rapidly, is characterized by smoothness, fluctuation 
and decided distention, which subsides some- 
what with occasional discharges of serum and 
blood. Sometimes small portions of the mass are detached and 
extruded, from which specimens it is possible to recognize the 
nature of the growth. When there is copious or continued hsem- 

* See page 369. 



ON THE DISEASES OF WOMEN. 535 

orrhage, the diagnosis from a uterine fibroid is more difficult. In 
this case a decision can be reached by dilatation of the cervix and 
an exploration of the uterine cavity by means of the finger or the 
uterine sound. 

It is quite impossible, in most cases, to distinguish an intra- 
uterine fibroid from a fibrous polypus, without artificial dilatation 

of the cervix and careful exploration, unless 

the polypus is large enough, and its pedicle suffi- 
ciently long to enable it to drop into the canal of the cervix, or 
into the vagina. Their differential diagnosis is, however, not a 
matter of very great importance. The only real difference 
between them is that the fibroid is enclosed in a proper capsule, 
which really disconnects it from the surrounding tissue ; while the 
polypus is a true out-growth, which is continuous with the sub- 
stance of the uterus and covered only by its lining membrane. 
These differences are not observable, however, until the growth 
has been removed. 

These fibroids have sometimes been confounded with the tumor 
formed by inversion of the womb. They have many symptoms in 

common. But inversion follows the evacuation 
wfrnT inversion of the of the uterus. Either the woman has recently 

been delivered, in abortus or at term, or the 
organ has first been distended and developed by a contained tumor, 
and finally turned inside out during or in consequence of its deliv- 
ery. The best test between these tumors, however, is a very 
simple one. In inversion the tumor is sensitive, and if you 
stick a pin into it the patient feels it ; but not so in case of the 
fibroid. 

By means of the uterine sound or probe alone you can diag- 
From retroversion and nosticate retroversion and retroflexion of the 
retroflexion. uterus from a sub-mucous fibroid. 

Prognosis. — There are several sources of danger in this disease. 
The haemorrhage may drain away the strength, and so undermine 

the health as finally to destroy life. Sometimes 

May die suddenly. 

such patients die very suddenly from excessive 
loss of blood. In consequence of the mechanical pressure of the 
tumor upon the pelvic viscera, or upon the ureters, serious disease 
may be caused in the bladder, the bowels, or the kidneys. The 
reflex disorders occasioned by the same cause are harassing and 



586 LECTURES, CLINICAL AND DIDACTIC, 

exhausting. The impairment of digestion, respiration, and espec- 
ially of the circulation are sometimes very serious. 

In some cases the symptoms are very deceptive, and give no 

reliable criterion of the gravity of the disease. Women who have 

carried these tumors about with them for years 

Symptoms deceptive. --it -i • i i niii 

with almost no complaint, and at last rind them- 
selves ill, are apt to drop off very suddenly ; while those who 
complain most bitterly are often in a less dangerous condition. 

The risk of operative interference is less than in either of the 
other varieties of uterine fibroids. There are two reasons for this 
fact : (1) because the tumor is more readily 
' reached and removed, and (2) because the dan- 
ger of consequent inflammation is in proportion with the liability 
of wounding or cutting into the peritoneal surface of the womb. 
Treatment. — The treatment is medical and surgical, or pallia- 
tive and radical. Whatever contingencies beset the case must 
first be removed. The haemorrhage is the 

Medical. 

source of danger and must be controlled. For 
this purpose such remedies as ipecacuanha, china, arsenicum alb., 
hamamelis, erechthites, crocus sat., cinnamonum, trillium, secale 
cor., sabina, belladonna, nitric acid, or ferrum met., may be given 
each under its appropriate indications. The suitable remedy will 
generally suffice to relieve the pain as well as the excessive 
flow. 

If the haemorrhage is copious and continuous, and it becomes 
necessary to stop it at once, in order to husband the patient's 

strength and to save her life, and internal 

Palliative. °. ' 

remedies act slowly or fail altogether, recourse 
must be had to such local treatment as was recommended in my 
lecture on uterine haemorrhage.* You doubtless remember what 
I then said of such available expedients as cold water locally and 
by injection, ice, ice-water, pouring cold water from a height 
upon the abdomen, colpeurysis, and the tampon. In some cases 
the sponge tent makes an excellent tampon for the cervix ; and 
Palfreyf recommends to introduce the speculum, to draw down 
the anterior lip of the cervix, and then, with the uterine sound to 
pack its canal with a long and narrow strip of lint. The lint, 
which may have been soaked in carbolized water, should be 

* See page 8o. f Medical Press and Circular, Vol. VII, p, 516. 



ON THE DISEASES OF WOMEN. 537 

allowed to remain for about twenty-four to thirty hours before it 
is removed. 

Among the improved methods of hsemostasis, which also 
include a more or less permanent exemption from the flow, there 

is no simple expedient that is more valuable 
osTa h tfc! P ° ngetentasahaem " tnan tlie introduction of the sponge tent. I 

have known it alone to prevent the return of 
the menorrhagia, and to secure a natural flow for months in suc- 
cession. 

In obstinate cases nicking, slitting or incising the os uteri with 
a curved, blunt-pointed bistoury, a pair of scissors, or the hyster- 

otome, has also been practiced with marked 

Incision of the cervix. 

success. Whether these latter means are effi- 
cacious because they unload the engorged vessels, or because by 
dilating the os uteri, they empty the womb of its more fluid and 
distensible contents, and thus remedy the difficulty, I am not pre- 
pared to say. But that they certainly present a valuable means 
of relief, which is always available, and which, until quite 
recently, was unknown, I am well assured. 

If this treatment fails to bring the desired relief, Dr. Atlee* 
recommends to follow up the section of the os uteri with a free 

division of the capsule of the fibroid in utero. 

Dr. Atlee's operation. 

I his he accomplished by means ol a long- 
handled, curved and probe-pointed bistoury, which is to be passed 
into the uterus as far as the guiding finger will reach, and then 
drawn firmly down over the tumor so as to cut through its capsule 
and into its substance to the depth of half an inch. This opera- 
tion not only lessens the haemorrhage, but so impairs the nutritive 
vitality of the fibroid that its destructive metamorphosis is soon 
established, and it will be either enucleated spontaneously, or 
thrown off with a kind of leucorrhoeal discharge. This practice 
seems to me to be especially adapted to tumors with a broad base 
and margin of attachment. 

But unless Dr. Atlee's operation shall result in the extrusion 

of the fibroid, either as a whole or in fragments ; or it shall be 

spontaneously detached and expelled, as it 

Excision of the tumor. . 

sometimes is, by strong uterine contractions; 
or unless it shall undergo some form of defeneration, and there- 

* Transactions of the American Med. Association, 1S5S, page 55S. 



538 LECTURES, CLINICAL AND DIDACTIC, 

by escape or cease to be troublesome ; a radical cure will only be 

possible by its excision and removal. This is to be effected by a 

ligation of the tumor. And two obstacles are 

First obstacle. . _ . i • i rm n 

in the way ot its accomplishment, lhe first 
of these is the narrow state of the cervix uteri. To overcome it 
we must resort to free dilatation. If the tumor is quite large, and 
the cervix is shortened and softened, as in the later months of 
pregnancy, two or three sponge tents of various sizes may be 
introduced successively. These will expand the neck so that the 
fingers can be passed within the womb, the exact site of the 
tumor ascertained, its mode of attachment also, and the instru- 
ment adjusted. For this must be done by the sense of touch, and 
not by sight. 

In the more rigid and unyielding states of the cervix, the sea- 
tangle tents are preferable. Of these quite a number are to be 

passed through the internal os uteri one after 

Dilatation the first step. . . 

another, until it contains from three to seven 
or eight of them. The longer these tents the better. They 
should be allowed to remain for from twelve to twenty-four 
hours. On their removal, if the dilatation is not sufficient, one 
of Barnes' rubber dilators may be inserted through the cervical 
canal, inflated, and left in situ for some hours longer. These 
expedients will provide a mode of entrance that will make the 
further steps of the operation possible. To secure a free expan- 
sion of the cervix, it may perhaps be necessary to incise it at the 
same time that you dilate it. 

The second obstacle in the way of operating in some of these 

cases is the difficulty of adjusting the ligature, or rather, the 

chain or wire of the ecraseur. If the tumor is 

The second obstacle. . 

m the vagina, and is not very large, there will 
be no trouble in this respect ; but if it is in the uterus, and 
more than all if it is attached to the fundus, and has a broad 
base, instead of a pedicle, you will find that it is not so easily 
done as you might have supposed. Indeed, it may require 
repeated trials before you succeed in carrying the loop of the 
ligature over and beyond the tumor. A few authors insist that, 
to facilitate this object, the uterus should be dragged down to the 
vulva. But, unless in very exceptional cases, this proceeding is 
barbarous and unnecessary. 



ON THE DISEASES OF WOMEN. 539 

To obviate the difficulty of which I have just spoken, Dr. Sims 

added a porte-chain to the uterine ecraseur, which so stiffened 

the instrument that its flexible part could be 

The ligation of the tumor. . 

more readily and certainly adjusted. As thus 
improved, the chain ecraseur is more useful than it was formerly ; 
but the majority of gynaecologists prefer that the ligature shall 
be made of wire instead of the chain. This can be worked in the 
frame of, and upon the same principle as the ordinary ecraseur. 
Dr. Braxton Hicks' instrument, which I hold in my hand, is a 
wire-rope ecraseur. 

In order to ensnare the tumor most readily, let me give you a 
hint which I have found of great service. First ascertain as 

accurately as possible the precise site of the 

A practical hint. _ ; 

tumor, and its point 01 attachment to the 
uterine wall. Then place the patient in such a position that it 
will drop away from its pedicle, or base, towards the opposite side 
of the womb. If it happens to be centrally located the position of 
the patient is less important. Fortunately a majority of these intra- 
uterine fibroids, and fibrous polypi also, groAV from the posterior 
wall of the womb ; and therefore the patient is usually placed in 
what is now known as the left lateral position. 

When the instrument is finally adjusted, all that remains is to 

tighten it slowly and steadily until the tumor is cut off. This 

should be done very graduallv, lest the wire 

Caution. J 5 -, , 

break. Iron wire will not stand the strain ; 
but the wire-rope or steel wire are more trustworthy. If the 
tumor is a very large one; it may need to be delivered with the 
obstetric or other forceps, or perhaps to be cut into pieces before 
it can be brought away through the os uteri. Fortunately, in 
ecrasement, there is an exemption both from immediate haemorr- 
hage and from the danger of subsequent inflammation. 

In rare cases, where the tumor is very large and pedunculated, 
and occupies the vagina, it is so difficult to excise it in the ordi- 
nary way, that it has been recommended first to 

An exceptional case. .."-.,,, . 

seize it with the obstetric forceps, and then to 
draw it out at the vulva, after which the e'craseur ma} r be applied. 
This operation causes a temporary inversion of the womb ; but 
the os having been stretched so widely by the tumor, and para- 
lyzed by pressure upon it, is not likely to contract so firmly as 



540 LECTURES, CLINICAL AND DIDACTIC, 

to interfere with the reposition of the organ afterwards. If there 
is much haemorrhage, the stump, or pedicle, may be seared with 
an iron at a white heat, or painted with the per-chloride of iron, 
before the uterus is replaced. 

H. — SUB-PERITOXEAL FIBROIDS. 

These growths, which are located on the exterior surface of the 
womb, and beneath the peritoneum, are also known as sub-serous, 
extra-mural and extra-uterine fibroids. They 
^Frequency, number, size, are i ess frequent than either of the other vari- 
eties, but when the}' do exist, are almost always 
multiple. They grow more rapidly, are of various sizes, and may 
be very numerous. Not unfrequently the abdomen will be filled 
with one which is very large, while the exterior of the uterus is 
studded with a number of smaller ones that are undeveloped. 
Sometimes, however, two or more of these tumors may grow 
together and not differ materially in their size and form. 

Symptoms. — Since they have no necessary connection with the 
cavity of the uterus, neither with its mucous membrane, nor 
indeed with the generative intestine ' in any way, the disorders of 
menstruation which are almost invariably present in the case of 
sub-mucous fibroids, are lacking in the sub-peritoneal variety. 
There is no especial liability to haemorrhage, or to serous dis- 
charges from the uterine cavity. 

The symptoms are therefore chiefly mechanical. Small tumors 

of this kind occasion very little inconvenience, and may exist for 

vears without symptoms. Larger ones drop 

Chiefly mechanical. . , . 

into the retro-uterine space, against the bladder 
anteriorly, or press laterally in such a way as to cause pain within 
the pelvis or in the corresponding hip and thigh. If it becomes 
pedunculated, as it frequently does, the length of the pedicle may 
permit the tumor to float, as it were, and to change its position 
with reference to the pelvic organs, so as not permanently to dis- 
place the uterus. But, when there is no pedicle, and the growth 
has a broad base, the womb is almost certain to be dislocated and 
more or less fixed in an unnatural position. 

" Pressure on the bladder, even without co-existing anteflexion, 
may become so considerable as to compress it between the sym- 



ON THE DISEASES OF WOMEN. 541 

physis and the tumor, giving rise, in consequence, to second- 
ary phenomena in the uro-poietic system. 
The hyperemia of the pelvic blood vessels, 
occasioned by fibroid tumors, is frequently manifested in the 
mucous membrane of the bladder as a varicose distention of its 
veins, especially of those situated at the neck of the bladder; 
and Rokitansky even observed a case of rupture of a submucous 
cystic vein, with haemorrhage into the bladder. Thomson relates 
a case in which a perforation occurred in the wall of the above 
organ from pressure of a large fibroid tumor, with adhesion of 
half of the periphery of the tumor to the borders of said per- 
foration. 

" On the other side pressure affects the rectum, and defecation 
may be completely prevented by fibroids impacted in Douglas' 
space. They may also cause varicose distention of the hsemor- 
rhoidal veins, and hyperemia of the rectal mucous membrane in 
the same way as in that of the bladder."* 

Hypostatic hyperemia, or engorgement, of the utero-vaginal 

mucous membrane is a very common result of the pressure from 

these tumors. And hence they are likely to be 

Coincident disorders. 1 1 . , . . 

attended, not only with uterine deviations, but 
with a coincident cervicitis, endo-cervicitis, endo-metritis, and 
vaginitis. Such local derangements of the circulation sometimes 
find vent in a critical haemorrhage which is inter-periodic, and 
sometimes (though rarely in this form of fibroid) in copious or 
prolonged menstruation. 

In these extra-mural fibroids there is a marked and character- 
istic tendency to peritoneal inflammation. In many cases this 

lesion is latent and circumscribed, and as a con- 

Liability to peritonitis. . 

sequence adhesions are formed which glue the 
tumor more or less firmly and generally to the neighboring parts 
or organs. At other times patients suffer from acute lancinating 
pains, are sick a few days, with a sharp attack of peritonitis, and 
then recover. Ail the suffering and all the sequelae, however, are 
usually, but improperly, referred to the tumor itself. These are 
the adhesions which are encountered on section in gastrotomy. 
Diagnosis. — The frequency with which this class of fibroids is 

* Pathological Anatomy of the Female Sexual Organs, by Julius M. Klob, M.D., etc. 
N. Y. 1868. p. 175. 



542 lectup.es, clinical and didactic, 

located tit the posterior cul-de-sac increases the liability of their 
being mistaken for retroversion or retroflexion 
ret F r r ofl?xion t . roversion and of the womb. But the physical signs will 
enable you to distinguish them. Perhaps the 
"touch" reveals a tumor which lies in the hollow of the sacrum, 
but it alone is insufficient as a means of diagnosis. The bi-manual 
examination will help you to decide whether the upper and ante- 
rior portions of the uterus are enlarged or the seat of an abnormal 
growth. But it will not serve to differentiate between a fibroid 
tumor in the posterior part of the pelvis and a retroverted or 
retroflexed uterus. To settle this question, therefore, we must 
pass the uterine sound. If the point of the instrument looks 
towards the superior strait, as it should, when it has reached the 
fundus, the tumor is a fibroid, and the uterus is not displaced 
backwards. I should not forget to remind you, however, that, in 
certain cases, these two disorders co-exist. 

Having already detailed the signs by which you would diagnos- 
ticate an extra-uterine fibroid from an ovarian 

From ovarian dropsy. 

tumor or cyst, it is unnecessary to repeat my 
remarks upon that subject.* 

So much depends upon the length and size of the pedicle in 
these cases that it is difficult to establish a rule of diagnosis 

between this form of fibroids and pregnancy. 

The uterus will be increased in its dimensions 
if the pedicle is short, and if the womb should grow and develop, 
the presumptive signs of pregnancy will be all the more promi- 
nent. There is, however, some considerable difference in the 
form and general character of the abdominal tumor in the two 
cases. In fibroids, if there is more than one, the outline of each 
can be recognized through the abdominal parietes. If these walls 
are thin, and not inordinately developed, the fibroid is felt to be a 
hard, firm, resistant mass, which imparts an entirely different sen- 
sation to the fingers from that of the elastic fluctuating sensation 
of the gravid uterus. Sometimes it is possible to feel the rounded, 
knob-like masses caused by smaller fibroids which are attached to 
the exterior of the uterus. 

The uterine souffle will be very similar in both ; but the possi- 
bility of hearing the foetal heart-sounds will sometimes enable 

* See pages 371-72. 



ON THE DISEASES OF WOMEN. 543 

you to decide between them. In fibroids the tumor develops very 
slowly, while in pregnancy the relative rapidity of its growth is 
much more marked. By withholding an opinion for a few weeks 
you may sometimes be able to settle the question of diagnosis very 
positively, on account of the size of the tumor having very much 
increased meanwhile, providing she is pregnant. Unmistakable 
quickening would also be diagnostic, but it must be real and not 
imaginary. 

In the later months, the condition of the os and cervix uteri, 
the more or less regular return of the menstrual flow, the inability 
to feel the movements of the foetus, the depth of the uterus as 
disclosed by the sound (which should not be passed if the signs 
of pregnancy are at all prominent, or unless in very extreme 
cases), will generally enable you to determine the diagnosis cor- 
rectly. Time is, however, an important element in this respect. 
It may require that you make several, examinations before your 
final decision is given. If so, and the patient is not in extremis, 
it will be well to allow the intervals between these several exam- 
inations to be somewhat prolonged. 

When pregnancy occurs in the case of a woman who already has 

one of these sub-serous fibroids, it is more likely to extend to term 

without accident than in case of the sub-mucous 

aborfion^ immunity from tumors of which I have spoken, probably for 

the reason that in the former the uterine cavity 

and its mucous membrane are nearly or quite normal. 

In these fibroids the previous history of the case ; the absence 

of grave constitutional symptoms, chill, fever, and a tendency to 

suppuration ; the fact that the tumor has been 

From pelvic cellulitis. 

growing tor months or years, and has no neces- 
sary connection with parturition, whether premature or not; 
neither with any traumatic or surgical injury ; would serve to 
distinguish this affection from pelvic cellulitis. Add to this that 
in cellulitis the uterus is almost always fixed and immovable, 
while in fibroids it is not so, and you can have no difficulty. 

The tumor that is sometimes formed by impaction of the faeces 
is in no manner connected with the uterus, is posterior to it, does 
From impaction of the not move with it, is doughy to the feel and can 
feces- be indented on pressure, is accompanied by 

symptoms of paralysis of the rectum, obstinate constipation, rec- 
tai tenesmus, and more or less of intestinal irritation. 



544 LECTURES, CLIXICAL AND DIDACTIC, 

Course and Termination. — Having free space, within the pelvis 

at first, and then within the abdomen, in which to grow, these 

tumors may reach a considerable size, and exist 

Toleration of. . 

m a dormant state lor years before they are 
observed or detected. And being, in most cases, unaccompanied 
by alarming or dangerous symptoms, harmless in themselves, and 
benign in their tendencies, their presence may be tolerated for 
many years more. 

Extra-uterine fibroids tend to develop into fibro-cysts, such as 
you saw in the case of Mrs. C. D , in this clinic, some weeks 

ago.* This cystic degeneration is one in which 

Cystic degeneration. . 

the tumor becomes composite, and instead of 
being made up exclusively of fibro -cellular tissue, as it was origi- 
nally, is composed of compartments, or cysts, which contain a 
quantity of serum, blood, or pus, or of all these commingled. It is 
only in case of the larger fibroids that this particular degeneration 
takes place ; and you should remember that, although it is by no 
means very frequent in the sub-peritoneal fibroids, yet it is much 
more rarely met with in either of the other varieties of this dis- 
ease. 

Prognosis. — Concerning ultimate recovery from this kind of a 
fibroid you had better promise nothing. Nature may extemporise 

a means of palliation and relief, through an 

Nature's attempts to cure. 

arrest of the development of the tumor, or even 
amputate it spontaneously by attenuation or rupture of its pedicle, 
so that it shall float around like a loose cartilage in the knee-joint, 
causing little pain or inconvenience ; but it is not probable that 
she will remove it entirely. Pregnancy is not so serious a com- 
plication in extra- as it is in intra-uterine fibroids. 

Although such a tumor may possibly co-exist with carcinoma 

uteri, }-et it is a settled fact that uterine 

No risk of cancer. . , .. 

fibroids have no malignant tendencies, and do 
not, therefore, develop into cancer. 

Treatment. — Physicians are agreed that, more especially in the 

early stages of these growths, internal medica- 
tre S a^men C t? mings ° f intemal tion should suffice for their removal and cure. 

But to say that it ever has cured them is to claim 
too much for our skill. In the present state of our knowledge, the 

* See page 426. 



ON THE DISEASES OF WOMEN. 545 

most that we can expect to accomplish with our remedies is the relief 
of contingent disorders and complications. And whether we shall 
ever improve upon this is largely a matter of " faith and works.'' 
If these tumors result from a simple hypertrophy of tissue, the 
resolvent powers of our medicines, locally and internally used, 
should be sufficient to arrest their development, if not indeed to 
cure them radically. Perhaps in the future we may be more suc- 
cessful with these means than we have been in the past. 

One grand difficulty in the way of this result, however, is the 

impossibility of placing such patients under proper treatment in 

the early stage of the disease, when the tumor 

Reasons therefor. ...... , 

or tumors are m their mcipiency, and when 
specific means would act more promptly and perhaps successfully. 
Another is that the differential diagnosis is so difficult ; and a third, 
that few women with these adventitious growths, or with uterine 
tumors of any kind (especially in these days of prize-surgery), 
are willing to take sufficient time to test the merits of internal 
treatment. 

The only surgical resource in case of the extra-uterine fibroid is 
gastrotomy. If the tumor has a well-defined pedicle, and its at- 
tachments are not very extensive or vascular, 

Surgical treatment. . - .. 

it may be removed, and the pedicle ligated, as 
in ovariotomy. A similar operation may suffice in case its stem 
or stalk is broken, and it is floating in the ab- 
dominal cavity. But, even after the abdominal 
incision has been made, if it is found that the growth is glued on 
all sides, and thoroughly amalgamated with the uterus and the 
neighboring parts, it is thought to be best to relinquish the opera- 
tion, to close up the wound and allow the tumor to remain. This 
course is deemed proper because of the danger that would almost 
necessarily follow from the final extirpation of the growth under 
such adverse circumstances. These dangers include the possi- 
bility of the shock or collapse, haemorrhage, fatal peritonitis and 
septicaemia. 

Notwithstanding these dangers, however, surgeons have pushed 

forward, and not only removed the fibrous 

Extirpation of the uterus or row th, but the uterus and ovaries also. The 

and ovaries. o ' 

proportionate loss of these patients has been 
very large, but no larger, it is claimed, than was the relative 

35 



546 LECTURES, CLINICAL AND DIDACTIC, 

number of deaths from ovariotomy in the early history of that 
operation. Out of 35 cases of uterine fibroids, in which the uterus 
and ovaries were extirpated, 7, or 1 in 5, recovered. 

" No operator should undertake gastrotomy for uterine neo- 
plasms without being prepared, if necessary, to remove the uterus 
with the tumor, for sometimes the connection is so intimate that 
an exact localization of the tumor is out of the power of the most 
skillful diagnostician. Indeed, even after the removal of the mass 
from the body, its relations to the uterus are often discovered only 
after patient and intelligent search. Dr. Farre tells of a speci- 
men preserved in one of the London museums as a solid ovarian 
tumor which, upon careful examination, he proved to be uterine 
by tracing the Fallopian tubes into it. It was also in this way 
that the nature of the tumor removed by Dr. Storer was identi- 
fied, Prof. Ellis, after a very minute examination, distinctly dis- 
covering the entrance of the tubes into the cavity of the body, 
and thus settling the matter."* 

*A Practical Treatise on the Diseases of Women, by T. Gaillard Thomas, M.D., 
etc. 3d edition, 1872. p. 501. 



ON THE DISEASES OF WOMEN. 547 



LECTURE XXXII. 

fibroid tumors of the uterus. — (Continued.*) 

Gentlemen : 

Having discussed the special pathology and treatment of those 
fibroids which are denominated intra-uterine and extra-uterine, 
we now come to speak of such as are located within the wall of 
the womb, midAvay between its mucous and serous coats. These 
tumors, which are not in the uterine, nor yet in the abdominal 
cavity, are commonly known as 

3. — INTERSTITIAL. FIBROIDS. 

They also have various synonyms such as intra-mural, intra- 
stromal, parietal, and intermediate. These are the round tumors 
proper, for no matter what their size, unless they are forced into 
the uterine or the abdominal cavity, and thereby become oval or 
perhaps pedunculated, their shape is unchanged. They are 
always enclosed within a proper capsule, and, like the other 
varieties, are most frequently located posteriorly with reference 
to the womb. In very rare cases they are met with at the lower 
segment of the uterus, and even in the cervix. But, wherever 
they are found, the neighboring portion of the womb is hyper- 
trophied, and all of its tissues are preternaturally developed. 

Symptoms. — The s3 T mptoms are more or less grave and trouble- 
some according to the size of the tumor and the tendency to 
inflammation within or about the womb. If 

Uterine deviations. . -i r» i • i 

the growth is large, and fixed m the posterior 
wall of the uterus, that organ will necessarily be displaced 
posteriorly. For this reason retroversion and retroflexion are 
almost invariably present in these cases. But if the tumor is 
attached to the side of the womb, the latter will, of course, be 
dragged, or made to incline laterally. 



548 LECTURES, CLINICAL AND DIDACTIC, 

In a considerable proportion of cases there is dysmenorrhcea. 

The difficulty of menstruation is due either to the partial closure 

or the tortuosity of the cervico-uterine canal, 

Dysmenorrhcea. . 

which is caused by the flexion of the uterus 
and the presence of the tumor ; or to the fact that this foreign 
body almost necessarily excites painful contractions of the 
womb whenever anything is to be extruded. 

In other cases, I think there can be no question that the obstruc- 
tion to the ready exit of the flow in dysmenorrhea may indirectly 
cause such a tumor to be developed. It is reasonable to suppose that 
such a derangement in the uterine circulation as almost necessarily 
accompanies very painful and tardy menstruation, would beget a 
vice of nutrition that might result in local hypertrophy. And 
thus, in exceptional cases, it might be very difficult, and perhaps 
impossible, to determine whether the dysmenorrhcea was the 
cause or the consequence of the interstitial deposit. 

On account of their nearness to and intimate relations with the 
uterine mucous membrane, there is almost as great a liability to 
menorrhagia in the interstitial as in the sub- 
mucous fibroid. The menstrual discharge is 
always too free, and the return of the periods is apt to be more 
frequent than natural. In many cases the flow is prolonged and 
continuous, the blood oozing away constantly. Or the haemor- 
rhage may be sudden and alarming, accompanied by violent pains 
and contractions like those of labor. Not unfrequently this 
condition of things is mistaken for abortion, more especially if 
shreds of membrane and coagula are expelled. 

The tendency to abortion is somewhat less marked than it is 

in the case of intra-uterine fibroids, -but this accident occurs more 

frequently in this than in the extra-uterine 

Abortion. . . 

variety. We can account for this clinical fact 
upon the theory that this adventitious growth diverts the nutri- 
tive supplies which are heeded by the developing embryo. 
Perhaps a better explanation is that the tumor, or fibroid, excites 
such peristaltic contractions as are likely to empty the womb of 
its contents. The unequal development of the uterine wall is 
' not without its influence also. 

I have now under treatment two cases of sterility, which are 
due to the presence of parietal fibroids. In both of them the 



Menorrhagia. 



OX THE DISEASES OF WOMEN. 549 

growths are so situated as to cause violent dysmenorrhea, and 
so decided a retro-flexion of the womb as ab- 
solutely to prevent the ingress of the semen 
masculinum. Under these circumstances insemination is impos- 
sible. In order to cure these women it will be necessary to 
remedy the displacement. But if conception were attained, they 
would almost certainly abort afterwards, unless the fibroid had 
been disposed of. 

Other incidental disorders are endometritis, cervicitis, leucorr- 
hcea, cystitis, proctitis, rectal ulceration and paralysis, inveterate 
constipation, haemorrhoids, pelvic cellulitis, and pelvi-peritonitis. 
Diagnosis. — In separating these from other foreign growths we 
are obliged to depend mainly upon physical signs. Examination 
is to be made with the ringer per vaginam, and per rectum, and 
with instruments -also, of the cervical and uterine cavities. The 
tumor must first be located, and afterwards identified. These 
steps are less difficult, perhaps, than mother fibroids, because inmost 
cases the tumor is pelvic and not abdominal, and because it is so 
located in the hollow of the sacrum as to be more accessible. 

The bi-manual method facilitates the examination by the 
"touch." The patient should be placed upon her back, the 
limbs flexed, and the abdominal parietes relax- 
^ The bi-manuai examina- e( j. The left hand is then to be placed upon 
the hypogastrium and pressure made upon the 
uterus over the pubes, so as to cause it to descend as far as pos- 
sible into the excavation, toward the ostium vaginas ; the index 
finger of the right hand being at the same time within the vagina, 
or the rectum, is made to explore the lateral 

Depressing the uterus. . . 

and posterior surfaces ot the womb in such a 
manner as to recognize any increased or abnormal development 
of its wall. 

Or, if the woman is corpulent, it may be necessary to draw 

down the uterus with a Sims' or Nott's tenacu- 

The uterine tenaculum. .. . , ... ,, , , 

mm, in order to examine it more thoroughly 

through the retro-uterine space. 

The probe may suffice to indicate the presence of a tumor, 
which presses towards the uterine cavity ; but 
in general it will not diagnosticate an intra-mural 

fibroid, excepting upon the principle of exclusion. Thus, if the 



550 LECTURES, CLLXICAL AND DIDACTIC, 

sound is passed without difficulty or obstruction, and takes the direc- 
tion of the proper uterine axis, the inference is that, if there is a fib- 
roid in the wall of the womb, it cannot be of any considerable size. 
For one of these tumors must almost necessarily displace the organ. 
A sub-peritoneal growth with a pedicle might fill the hollow of 
the sacrum without chanoino; the axis of the womb, but not so 
with an interstitial fibroid. 

However, if you can not satisfy yourselves of the existence of 

an intra-mural tumor, by the conjoined methods of which I have 

spoken, it will be necessary to proceed to dila- 

Dilatation. . . 

tation, in order to be able to explore the cavity 
of the womb with the finger or other instrument. This may be 
done in the manner indicated in my last lecture. It should be 
done cautiously, howeA'er, lest you induce a severe haemorrhage. 

The differential signs between an interstitial fibroid and pelvic 
cellulitis, pelvi-peritonitis, and kindred affections, with which it 
is sometimes complicated, and for which it has been mistaken, 
are the same as those by which you would distinguish these dis- 
eases and other sequels from sub-mucous and sub-serous fibroids. 
Prognosis. — My own experience leads me to conclude that this 
variety of the myo-fibromata is more amenable to treatment than 

either of the others. Unless it be excessively 

developed, or attended by unusual haemorrhage, 

or other dangerous complications, from which this class of fibroids 

is not exempted, you should not despair of curing your patient. 

A favorable change is likely to follow the menopause. This 

crisis once passed, the chances are that with the subsequent 

atrophy, or senile involution of the uterus and 
onife Uence ° f the change the ovaries, such a growth may also undergo a 

retrograde metamorphosis, and never occasion 
any more trouble. Sometimes, however, these fibroids cause the 
climacteric to be delayed, and the menstrual flux to be substi- 
tuted by prolonged and dangerous haemorrhages, which have a 
fatal tendency. 

In bad cases, where the cervix is long and narrow, as well as 

dense and undilatable. occurring in women who 
cei^ e . c ° nditionofthe nave never been pregnant, the prognosis is 

generally unfavorable. Indeed, the texture, 
consistency and other physical characters of the neck of the 



ON THE DISEASES OF WOMEN. 551 

womb, have more to do than almost anything else with the possi- 
bility and probability of cure, whether by surgical or medical 
means. Other things equal, multiparas are more likely to recover 
than nulliparae. 

While the fatty, calcareous, cartilaginous, and even the osseous 
degenerations which these fibroids sometimes undergo, are to be 

considered as salutary in their tendencies, other 
er JdoJi° us f ° rms ° f degen " varieties of textural change may imply increased 

danger. Suppuration, sloughing, oedema, and 
interstitial haemorrhage are critical processes that will cause you 
the greatest anxiety, and which you will learn are beset with 
extreme peril. The spontaneous enucleation of the tumor is alto- 
gether favorable. An evident inclination in the fibroid to develop 
in the direction of the uterine cavity, and especially to become 
pedunculated, is not of necessity a bad sign, for it may facilitate 
its removal by surgical means, or otherwise. 

When complicated with other diseases, the danger varies with 
the grade and character of the contingent disorder. In women 
of a haemorrhagic diathesis the chances of recovery are not the 
most promising. 

Treatment. — I am aware that there is a sort of histological 
difference between a simple hypertrophy of the uterine wall and 

an interstitial fibroid ensconced in its capsule. 
Curable in their incipi- g u ^ this difference is more apparent than real. 

ency. *■ x 

The early clinical history of these fibroids is 
so closely related and allied to those changes which take place 
within the same tissues during utero-gestation, and their post- 
partum involution, as to convey a therapeutical hint which prom- 
ises to be of especial service. And I am persuaded, as the result 
of experience, that, in their early stages, these tumors are often 
curable by the use of internal remedies conjoined with very simple 
local means. 

It is therefore a most fortunate circumstance that these pari- 
etal fibroids are more likely to be recognized, and to come under 
our care at an earlier period of their existence than either of 
the other varieties of this affection. It is for this as well as 
for diagnostic reasons, that I have chosen to treat of them 
separately. 

Manifestly, the first duty of the practitioner is, if possible, feo 



552 LECTURES, CLINICAL AND DIDACTIC, 

prevent their recurrence. This may sometimes be accomplished 
through the adoption of means that are calcu- 
lated to ensure the complete and uniform invo- 
lution of the uterus after delivery ; the free and ready exit of the 
menstrual flow ; to prevent such habitual or permanent deviations 
of the womb, particularly retroversion and retroflexion, as would 
result in its disproportionate development ; the prevention of 
abortion, and its consequent arrest of the organic changes proper 
to pregnancy ; the interdiction of intemperate and fraudulent 
intercourse ; and of the wearing of pessaries, stays, abdominal 
supporters, and of whatever might interfere with a free and unin- 
terrupted distribution of blood through the pelvic and abdominal 
viscera. This preventive treatment is very important. 

And so likewise is the medicinal treatment. The haemorrhage 

and the serous discharges, as well as the symptoms which are 

attendant upon the local inflammation and the 

Medicinal treatment. . 

menstrual disorder, afford a series of definite 
indications for our remedies. We make requisition upon the 
materia medica for secale cornutum, sabina, sepia, belladonna, 
lachesis, crocus, calcarea carb., staphisagria, arsenicum alb., sili- 
cea, phosphorus, lycopodium, china, thuja, carbo vegetabilis, sul- 
phur, or nitric acid. One of these is given upon specific indica- 
tions — which should be as definite and accurate as possible — and 
its use is persisted in until the symptoms for which it was pre- 
scribed have disappeared. Then another may be chosen. 

I could detail a number of cases in which the careful and per- 
sistent employment of belladonna has removed 
a limited hypertrophy of the womb which, but 
for it, would undoubtedly have developed into a fibroid. It was 
given in the third decimal attenuation. 

Lachesis is equally efficacious in certain cases. It seems pos- 
sessed of remarkable virtues as a resolvent, particularly where 
there is a defective involution of the womb. I 
am not aware that any author has mentioned 
this fact, and you will therefore take my individual estimate of 
its value for no more than it is worth. No class of facts needs 
such abundant confirmation as those which are clinical. In my 
hands the best effects have been derived from lachesis in the sixth 
and the twelfth attenuations. 



ON THE DISEASES OF WOMEN. 553 

In claiming that these tumors are curable in their incipiency by 

means that are so mild and available, I do not forget that there 

are many sources pf fallacy which might lead to 

Sources of fallacy. . _ , • ,1 nn £ 

a wrong inference respecting the efficacy 01 
this or any other plan of treatment. It is not unusual for these 
growths to increase or to decrease in size very rapidly, and 
sometimes to disappear spontaneously. A retrograde metamor- 
phosis may take them out of the way. The climacteric may 
arrest their development ; and other changes may cut off their 
nutrition and cause them to wither. These cures by limitation 
are often placed to the credit of such agencies as animal magnet- 
ism, spiritualism, electricity, and other imponderables, and even 
of medical treatment. But, making due allowance for all these 
exceptional cases, I apprehend, it remains that very great good 
of a positive kind may be done by means of fitly-chosen internal 
remedies. 

Together with these remedies, as already indicated, I am in the 
habit of employing the cotton tampon saturated with pure glyc- 
erine, or with glycerine containing a few 
drops of the strong tincture of calendula, of 
hamamelis, hydrastis, or of the same medicine that is being taken 
internally. This is an excellent adjuvant to the cure, and has the 
effect in many cases to avert the recurrence of frequent and dan- 
gerous haemorrhages. 

The surgical treatment contemplates the removal of the tumor 

either by excision or enucleation. Excision by the ligature or 

the ecraseur, not being available in non-peduncu- 

Surgical treatment. 

lated growths, as a rule, and these fibroids 
being interstitial, the main dependence is upon some form of 
enucleation. This operation consists in making one or more free 

incisions into the tumor and through its cap- 

Enucleation. _ p 

sule, trom the interior surface of the uterus. 
The fibroid is then turned out of its bed and, if possible, detached 
and removed at once. In many cases it is only partially separ- 
ated, and then allowed to slough away, care being taken mean- 
while to avoid pysemia and similar contingencies by frequent 
injections of carbolized or calendulated water', and appropriate 
internal medication. 

Although the risks of this expedient are sometimes very great, 



554 LECTURES, CLINICAL AND DIDACTIC, 

still it is growing in favor. It is sometimes resorted to for the 
removal of the sub-mucous fibroids also, particularly in case of 
such of them as are attached to the uterus by a broad base. 

Dr. Atlee's operation is a modification of this. And so also is 
Dr. I. Baker Brown's plan of coring or " gouging " out a piece 

from the middle of the tumor and filling the 
o ?rations ees and Browns cavity with lint that has been dipped in olive 

oil. The idea in both of these operations is to 
impair its nutrition, and to facilitate the sloughing and separation 
of the adventitious growth. 

In some of these cases there is such an exceptional intolerance 
of artificial dilatation of the cervix uteri, both on account of the 

hemorrhage that may follow, and of directly 

Danger in dilatation. 

fatal results, that the greatest possible care is 
requisite in the preparation of the patient for the removal of the 
tumor. Dr. Thomas reports two cases of sudden death from the 
use of the sponge-tent preparatory to enucleation, and sums up 
the dangers of this whole operation in the following forcible lan- 
guage : " If the cervical canal be well dilated, and the uterus sus- 
ceptible of depression to the ostium vaginae, or the vagina be so 
dilatable as to admit the hand, the case should be regarded as 
favorable to the procedure. If the opposite state of affairs exists, 
the case is not only an unfavorable one, but the procedure will 
in all probability fail. The prospect of success is, for these rea- 
sons, much better in multiparous than in nulliparous women."* 

ALBUMINURIA IN PREGNANCY. 

Case. — L. W. C , 19 years of age, primipara, weighing 

180 pounds, was admitted to the hospital at the eighth month of 
pregnancy. She is of full habit and is troubled with headache 
and " flushes/' On being tested by heat and nitric acid, the 
urine was found to be highly albuminous. She had previously 
taken apocynum can., and arsenicum alb., without any benefit. 
The feet and legs were enormously swollen, so that she could not 
walk or stand with any degree of comfort. She felt wretched, 
nervous and apprehensive. 

She took mercurius corrosivus in the 3rd decimal trituration 
once in three hours. The proportion of albumen in the urine 

* The American Journal of Obstetrics and the Diseases of Women and Children, 
1872. Vol. V, page 108. 



ON THE DISEASES OF WOMEN. 555 

lessened almost immediately, and continued to decrease, so that 
there was a mere trace of it the day before her delivery. Although 
we had anticipated convulsions, her labor came on naturally, and 
was completed without a single untoward symptom. Her child is 
now three weeks old, and all the dropsical and urinary symptoms 
have entirely disappeared. 

I do not know where you will find a case of disease which is 
the cause of greater mental strain and anxiety than such a one as 
this has been. To feel and realize that in all probability a woman 
who is approaching term will have puerperal eclampsia, and that 
her life and that of her offspring depend almost entirely upon 
your skill, is a great load to carry. It should interest you to 
know how such a calamity may sometimes be averted. 

A pregnant woman at the eighth month may have dropsical 

symptoms which do not forbode any ill of this kind. But if she 

has decided albuminuria, with dropsy of the 

Signs of convulsibility. . . . . 

lace and extremities, with or without amauro- 
sis, the probabilities are that unless this is relieved, her delivery 
will be accompanied by convulsions. How to remedy this single 
symptom may therefore be a very important question for you to 
decide. 

Experience has led me to place great confidence in the mercu- 
rius corrosivus. I have prescribed it very frequently to fulfil this 

precise indication, and it has seldom disap- 

Mercurius corrosivus. . -rx a n t p«it 

pointed me. Dr. Adams has furnished me 
notes of another case which occurred in the hospital some weeks 
ago, in which the effect of this remedy was equally satisfactory. 

Case. — Nancy J., aged 29, primipara, was eight and a half 
months advanced in her second pregnancy when she was admitted 
to the hospital. She reported that she had had dropsical symp- 
toms for two weeks already. The legs and ankles were very 
much swollen, the ankles being so puffy that the infiltrated 
integument hung over her slippers. The face and eyelids were 
©edematous, and she complained of much headache. On exami- 
nation the urine was found to be albuminous. She also had a 
partial amaurosis, which began and subsided with the dropsical 
symptoms. 

She took the murcurius corrosivus 3, a dose every three hours. 
The albumen disappeared from the urine, so that the day before 
her delivery no trace of it could be discovered. She passed 
through parturition and lying-in without any convulsions. 



556 LECTURES, CLINICAL AND DIDACTIC, 

In presenting these cases the idea which I design to convey 

is not that this, or any other remedy, is an absolute specific for 

ante-partum convulsibility. ' There is no real 

There is no infallible . . , 

prophylactic for convuisi- prophylactic ot puerperal eclampsia. But if m 
one case in ten, you can recognise the incipient 
symptoms of this dreadful disease and avert it, you should know 
how to do it. Therefore, I recommend you not to fail to apply 
the tests for albuminuria whenever any of its symptoms are pres- 
ent in the later months of pregnancy, and not to forget that the 
mercurius corrosivus is in many cases an invaluable remedy for 
it. When Nature " flags the train " we should always take the 
hint. 

OVARIAN IRRITATION. 

Case. — Mrs. K , English, 54 years old, the mother of eight 

children, has been in poor health ever since her " change," which 
occurred seven years ago. Prior to that she had always enjoyed 
good health, although she confesses that she " was always very 
nervous." Once, however, she has had a pretty severe attack of 
gout in her right foot, and occasionally rheumatic lameness in her 
right arm. It was her habit, while she continued to menstruate 
to flow more freely than most women, and after the birth of some 
of her children she had severe haemorrhages. But, notwithstand- 
ing this, the climacteric passed without any flooding, or any dan- 
gerous symptoms Avhatever. The only complaint for some months 
after the flow had ceased was of a congestive headache, which 
alternated with a severe aching, sickening, burning pain in the 
left hypogastric and iliac regions. Finally the headache left, but 
the ovarian sufferings continued. 

For some weeks past she has been subject to occasional out- 
breaks of diarrhoea, which alternate with constipation, with 
scybalous stools and cutting colicky pains in the abdomen. She 
is extremely nervous and excitable, has globus hystericus and very 
copious urination now and then, and finds herself " very uncertain." 

On inspection the abdomen is uniformly distended. There is 
evident meteorism, which is general. Palpation does not disclose 
the presence of any tumor or enlargement. The left ovarian 
region is tender to the touch and to moderate pressure, but not 
especially so to firm pressure with the tips of the fingers. The os 
uteri is not abnormal. The uterus is in situ and mobile. The sound 
passes readily to the depth of two inches by actual measurement. 
Bi-manual examination does not reveal anything abnormal. 

Ovarian irritation is not an infrequent sequel to the climateric. 



ON THE DISEASES OF WOMEN. 557 

It is often the cause of ill health among those who, like this 
woman, have ceased to menstruate. But 

At the climacteric. . . . 

there is a combination 01 circumstances which 
constitutes a strong predisponent to this affection in such persons, 
and which is well illustrated in the case before us. Her habit of 

menstruating very freely, while that function 

Complications. . . i .-i n -i i 

was intact, and ot flooding m childbed ; her 
rheumatic diathesis ; and her hysteric constititution, render it 
almost impossible for her to have escaped the disorder from which 
she is at this moment suffering. 

Fortunately, she did not experience any severe or alarming 

haemorrhage at the menopause. In this respect the menstrual 

function ceased without any untoward symp- 

Analysis of the case. T . 

toms. In so far, her case was an exception to the 
rule that the hsemorrhagic diathesis predisposes to critical floodings, 
which may damage the general health, and endanger life. But 
this very exemption may have acted as an exciting cause, and 
prompted the development of the rheumatic and hysterical ten- 
dencies. As a matter of course, under these peculiar circum- 
stances, the ovary (and the left ovary especially) would be more 
liable to implication than any other organ. 

Hence a train of symptoms that are compounded of hysteria 
and rheumatism. If, instead of being predisposed to these affections, 

she had had a constitutional bias toward cancer, 

Clinical inference. n .. i • i -i, -iii 

dropsy, or tuberculosis, the result would have 
been very different, and the case would probably have developed 
into one of cancer of the womb, or of the mammary gland, or she 
would most likely have had an ovarian cyst, or some form of 
phthisis. 

You can scarcely err in ascribing a sickening, burning pain, 
with aching in either of the iliac regions, to irritation or inflam- 
mation of the ovary. No matter what other 

A pathognomonic sign. . . 

symptoms are superadded, 11 this is frequent 
or constant, the primary lesion is in that organ. The patient may 
have any of the manifold signs of hysteria, or she may have indi- 
gestion and diarrhoea, or constipation, or all these in alternation, 
and yet the focal point of the disorder will be either in one or in 
both the ovaries. 

Among the exciting causes of ovarian irritation which Ave have 



558 LECTURES, CLINICAL AND DIDACTIC, 

not already enumerated, are the indulgence of such habits, and 
the subjection to such emotional influences as 
tend to derange the circulation and innerva- 



Exciting causes. 



l fc> 



tion of the generative organs. One of my patients had this 
disorder in a most intractable form in consequence of taking 
vaginal injections of cold water, and sometimes of ice-water, 
several times daily for more than two years. In another it was 
caused by horseback riding. It frequently originates in the 
sudden arrest of a leucorrhceal discharge by astringent injections. 
A fertile source of this affection is the habit of staying at home, 
and of going very little into the open air ; for, contrary to what 
you would suppose, nothing allays a sur-excitation of the female 
sexual system like exercise or exposure out of doors. 

In order to show you how these simple causes operate, and how 
complicated the resulting affections sometimes are, I will read 
you the notes of a case in which I was recently consulted by 
my friend and former pupil, Dr. A. W. Woodward, of this city, 
who has reported its history for me : 

Case. — Mrs. B , a middle-aged, slender, and somewhat 

delicate woman, with three children, has usually enjoyed good 
health. During the last few months she has been too closely 
confined with family cares, and spent too many hours at the sew- 
ing machine. In consequence, she began to be troubled with a 
more or less severe pain, sometimes acute in character, located in 
the left hypogastrium. This pain is aggravated by standing upon 
the feet for any considerable time, and is much more severe and 
continuous just before the menses. It extends through the whole 
length of the left limb. The flow had always been normal until 
within the last two months, since which time it has been both 
protracted and profuse. 

A lady practitioner diagnosticated " retroversion and prolap- 
sus," and treated her by a severe and prolonged application of gal- 
vano-electricity. As a consequence the patient was completely 
prostrated, the pain was greatly increased, and instead of being 
merely indisposed, she became quite ill. At this stage I was * 'led 
in, and finding no signs either of retroversion or of prolaps or 
of anything to contra-indicate the use of stimulants, they re 
given, with good effect. Hot fomentations relieved the pair., ad 
as this subsided it was followed by a copious diuresis, for whioh I 
gave ignatia. 

This remedy was continued until the next day, when I found 
her with heat and slight swelling in the region of the left ovary. 



ON THE DISEASES OF WOMEN. 559 

a rapid pulse, thirst and headache. The pain still continued, hut 
was throbbing and not of the " sickening" kind that she had had 
before. I prescribed atropine and mercurius sol., and although 
she had a marked chill followed by heat during the afternoon, 
these remedies were given until the next morning. Arsenicum 
caused the strength to return, the pain to be lessened, and there 
was no sign of a chill for several days. 

But as the ovarian difficulty subsided, the stomach began to be 
deranged. At different times anorexia, cramps, acid eructations 
and vomiting were present. The symptoms would yield very 
readily to mix vomica, and then be followed either by a return of 
the ovarian irritation, by diarrhoea, or by a chill, after which these 
different affections would terminate with a profuse flow of urine. 
Then the same series of gastric, intestinal, ovarian and febrile 
symptoms would recur and run through their course as before. 
There was, however, no apparent order in their coming, excepting 
that the diuresis came last, 

The remedies that we prescribed jointly did this patient but 
very little permanent good. It was not until the cause of her 

suffering was discovered, or rather until it dis- 
flefh p " culiar " thorn in the closed itself, and was removed, that she got 

well again. This cause proved to be the pres- 
ence of a pestilent old female relative, who gave the poor woman 
no peace, upset her domestic affairs, and finally proposed to carry 
off her valuables in the wrong trunk ! 

Having already detailed the proper means of preventing this 
form of sexual irritation, and of its general management,* 

it only remains to speak of the remedies that 

may be indicated. Among these the most pro- 
minent is macrotin. In many cases it is an invaluable, and 
indeed an indispensable remedy. Belladonna, atropine, ignatia, 
rhus tox., zincum val., platina, colocynth, china, chamomilla, 
hamamelis, and the lilium tigrinum are equally useful under their 
appropriate indications. 

T e symptoms, in the case of Mrs. K., call for ignatia. 
St vill therefore take this remedy once in three hours, and 
re; . I have no doubt that it will relieve much of her suffering, 
but! this does not justify me in claiming that it alone will effect 
a radical cure. 

* See pages 165-6-7. 



560 LECTUKES, CLINICAL AND DIDACTIC, 



LECTURE XXXIII. 



amenokrhgea. — menorrhagia. — convulsions. 

Gentlemen : 

. I have had frequent occasion to extol the virtues of Nitric- 
Acid in a certain form of menorrhagia. Here are the notes of a 
case for which I am indebted to Dr. W. H. Parsons, of the Class 
of 1870-71 : 

Case. — Miss , twenty years of age, of nervo-bilious tem- 
perament, with dark hair and complexion, black eyes, and small 
in stature, had been ill for nearly four years. For the first eight 
years of her life she was puny and small, and, though never very 
ill, the skin was always of a yellowish hue, and the flesh veiy 
soft and flabby. At the eighth year she began to grow in height 
•and breadth, and finally became very fat. She continued so until 
her fifteenth year, when her menses appeared. At the second 
month she began to have a peculiar discoloration of the skin in 
various parts of the body. There were dark circles about the 
eyes, with languor, a morbid appetite and a general chlorotic 
condition, and the catamenia did not return. 

The doctor under whose care she was placed succeeded in bring- 
ing on the menses, but the flow did not cease at the proper time. 
The discharge was muco-sanguinolent, dark and offensive, and 
lasted at first about a fortnight. After this it became continu- 
ous, and she lost the record of the month. This state of things 
was unchanged for several months more when the mother 
besought the doctor to stop the IIoav. Some unknown medicine 
was given which had the desired effect, but she went into convul- 
sions, and the doctor, having decided it as hopeless, relinquished 
the case. As soon as the effect of the drug passed off, the flow 
returned and the convulsions ceased. 

This was followed, however, by twitching of the voluntary 
muscles. For about six months these symptoms continued and 
increased in severity, and her parents abandoned all hope of her 
recovery. Another physician was called, who diagnosticated the 
case as one of menorrhagia. He proceeded to suppress the dis- 



ON THE DISEASES OF WOMEN. -561 

charge and re-produced the convulsions. He then declared them 
epileptic, and treated her for epilepsy. But the girl grew weaker 
and more nervous, and finally he also abandoned the case, saying 
that " she would either outgrow it, or would ultimately die of 
it."' 

At the beginning of the third year Dr. was called. He 

declared it to be a passive menorrhagia, and prescribed hamamelis, 
creasote, secale cor., pulsatilla, etc. With these remedies the 
flow was arrested without bringing on the convulsions, and for a 
time the patient seemed to improve. After this she had amenor- 
rhcea (suppressio mensium), for several weeks, and then for six 
months more alternations of suppression and continuous flow. 
She was finally reduced to a mere shadow, passed sleepless nights, 
her right side was constantly in motion, and she was anxious to 
die for the sake of relief. 

Another physician was called, the patient improved, under 
senecin, gelseminum, and secale cor., and the parents soon thought 
they could " get her along" without the doctor. So far as the 
discharge was concerned, she was in a somewhat improved con- 
dition. But generally she was no better. In a few months the 
old difficulty returned with renewed violence. 

I found the patient in the following condition. She is very 
much emaciated, and hardly able to walk ; flesh flabby, skin soft, 
discolored in spots, very sallow and dirty looking, hectic flush, 
sensitive, alternate chilliness and flushes of heat, eyes brilliant, with 
dark circles about them, and constantly moving from one object to 
another. Sometimes she sits and stares like an idiot, and acts in 
a very silly manner. She also complains of pains in the top and 
back part of her head. The pulse is quick, small and irregular ; 
respiration hurried ; her body is in almost constant motion, her 
right foot and hand are very restless, particularly at night ; starts 
in her sleep as from fright. She rises at six A.M., but soon returns 
to bed, and almost immediately falls into a deep sleep which lasts 
about two hours, after which she feels weary and languid. She 
dislikes society, is fond of seclusion, and is very despondent. 
Complains of pain in the dorsal region of the spine. The stomach 
is very irritable, with a constant feeling of " goneness," eats little, 
food irritates and causes pain in the stomach. Craves acids, can 
not eat either pastry or hearty food. Tongue is coated and of a 
bluish white color. The bowels are bound, the urine high 
colored. No pain in the uterine region. 

The vaginal discharge is of a muco-sanguineous nature, very 
dark and foetid, darker than the proper flow, with occasional 
clots. 

I stipulated that she should eat what T directed, and nothing 
else, that her room should be changed from a dark and curtained 

36 



562 LECTUKES, CLINICAL AND DIDACTIC, 

dungeon to an airy, pleasant one, exposed to the sunlight, and 
that she should continue under treatment until I pronounced her 
cured, whether it took a month or a year. She was to take all 
the apples and oranges that she could eat, to exercise lightly in 
the open air, and to forego her exhausting sleep in the morning. 
The remedy prescribed was nitric acid 3 (centesimal), four pellets 
three times each day. 

April 17, two da} r s later, no change excepting that her stomach 
is less irritable, and bears food a little better. Continue the 
medicine. 

April 19, improved ; thinks the flow less ; appetite better ; but 
is very nervous and wakeful. Coffea 6 one dose at bed-time, and 
nitric acid as before. 

April 23. Continues to improve ; rested much better ; the 
discharge is very much lessened ; appetite improved ; pulse less 
frequent and more regular. Continue. 

April 26. Improving. Repeat the acid only twice per day. 

April 29. Flow completely stopped. Is very restless, can not 
lie or sit still ; starts at the least noise, seems afraid of every one, 
must get out of bed, looks wildly about, can not sleep. Hyos- 
cyamus two doses at night. Nitric acid discontinued. 

April 30. Slept well, feels refreshed; had the best night's 
rest that she has had for months. Hyoscyamus as before. 

May 3. Better, sleeps well, is more inclined to talk, and less 
nervous ; eyes less brilliant, appetite better, very little pain in the 
head. A slight discharge from the vagina. Nitric acid again, two 
doses to be taken each week. 

May 15. Found my patient much improved. She has passed 
through her menstrual period, which lasted four days and ceased 
spontaneously two days ago. She feels like a new creature, 
sleeps like a child, appetite good, stomach bears food well, no 
head symptoms, is cheerful and hopeful, glad to see her family 
and friends, her skin is almost natural, and, in brief, she appears 
well. 

Three months later (Aug. 10th), I called upon my patient and 
learned that she had quite recovered, and was in every respect the 
opposite of what she had been. The nervous symptoms had 
vanished, the menstrual irregularity had disappeared, and her 
health was entirely restored. 

This case illustrates the ill effects of " forcing the flow" at 
puberty. Here is a young lady of fifteen years. Nature is mak- 
ing an effort to establish the menstrual function. 

Emmenagogues at puberty. . . 

bhe is passing through the preliminary stage or 
the crisis, has been sick once, and in due time all will be well. 



OX THE DISEASES OE WOMEN. 563 

But her incidental ill-health alarms the parents. A doctor is 
called, and he decides that the " change" is not progressing as it 
should, and that all her difficulties are due to the delay in men- 
struation. Thus far his opinion is well enough. But, forgetting, 
if he ever knew, how delicate the function of ovulation neces- 
sarily is, with what contingencies it is beset, and how easily its 
proper performance may be deranged, he prescribes something that 
is designed, not to prompt, but to compel the flow. 

The consequence is that a train of ills, which might have been 
avoided, is fastened upon her. The flow appears, but it is not 
physiological and healthy. Instead of being 
followed by a spontaneous return in four 
weeks, it does not come at all. A little more medicine, and more 
of tinkering with the most marvelous of all the wonderful pro- 
cesses of the living animal body, and, as if to revenge itself, the 
discharge commences and continues indefinitely, or until it is 
checked again by powerful astringents. 

Now, gentlemen, you know the mischief of the artificial induc- 
tion of abortion. I have shown you how ruinous it is to the 
health of a woman to forcibly interrupt the 

Remote consequences. . 

attachments and growth 01 the germ. In this 
clinic your attention has been called to some of the sequelae of 
this abominable practice. But, let me tell you that, leaving the 
foeticide out of the question, the consequences to the woman are 
no more serious and lasting than those which frequently follow 
the taking of emmenagogues by young girls who are but just be- 
ginning to menstruate. 

The fact that with this patient the menses had already appeared 
should have been a sufficient guaranty that, if she were well in 

other respects, the flow would be regularly 
Menstrual intermissions established. And besides, as every experi- 

common. J i. 

enced practitioner will attest, nothing is more 
common than for the " periods," after having come once or twice 
at puberty, to be irregular. Sometimes they skip one month, or 
two or three, or perhaps even a year, before they return again. 
And this without any material damage to the general health. 

By and by, unless the doctor or ihe nurse is 

Let them alone. ... , . , 

impertinent, ignorant or mischievous, they are 
resumed with very little risk, and afterwards become quite regu- 



504 LECTUliES, CLINICAL AND DIDACTIC, 

lar. But, if you will observe carefully, I think you will find that 
in a very large proportion of cases of intermittent and irregular 
menstruation, amenorrhoea and menorrhagia, the difficulty is 
traceable to mal-treatment of this kind, at or about the period of 
puberty. In this manner it is quite possible for a single doctor, 
who has a passion for what he calls " demonstrative treatment," 
to sow the seeds of evils that fifty better men can not remedy. 

The relation between the nervous system and the menstrual 
function is also shown in this bit of clinical history. When the 

haemorrhage was suddenly checked the patient 
m^st e ruai r funcdons! he na d a convulsion, and when the flow returned 

the convulsions ceased. Each time the dis- 
charge was lessened, the nervous twitchings and choreic move- 
ments became more manifest. And even when the convulsions 
were not induced by an arrest of the menses, these jerkings and 
twitchings were very troublesome and persistent. It really 
seemed as if the patient was "decreed" to have either the 
menstrual disorder or the convulsive affection. The problem 
in the treatment was how to cure the one without causing the 
other. 

You are aware that the liability to hysterical convulsions, 
spasms and paralysis, is limited to menstrual life. In girls, 

chorea, or St. Vitus' dance, subsides as pu- 

Illustration. ' 

berty approaches, and finally disappears when 
the catamenial function is established. There is a form of men- 
strual mania that may accompany amenorrhoea, or menorrhagia, 
which, in many respects, resembles puerperal mania. All of 
which illustrates the intimate and profound relation between the 
menstrual function and the function of innervation. 

Another item that we should consider in this connection is the 
folly of supposing that, in certain cases of uterine hemorrhage, 
the disease is cured if we only stop the flow. 
There are cases of flooding in which if we f rial 
this indication it is all that we can expect to accomplish, for in so 
doing we shall necessarily remove the cause of the trouble. Such 
cases are those in which the loss of blood depends upon the pres- 
ence of polypi, fibroids, hydatids, or of the 

A practical distinction. *■ _ 

placenta m utero, upon cauliflower excres- 
cence, or the more ordinary form of uterine cancer. These can 



" Stopping" the flow. 



ON THE DISEASES OF WOMEN. 56b 

frequently, and indeed generally be relieved most speedily and 
certainly by surgical together with medical means. 

But in such cases as this, where the haemorrhage depends upon 
a pathological condition of the uterine mucous membrane, and a 
morbid state of the whole menstrual function, it will not suffice 
to check the discharge. For, even if the patient escapes having 
more alarming symptoms in consequence, the disease which has 
caused the flow is not cured thereby. The remedy must be pos- 
sessed of an intimate, curative relation to the lesion that under- 
lies and has occasioned this particular symptom, else it will do no 
permanent good. 

The digestive derangement was a very natural and almost 

necessary consequence of the menstrual disorder. And so also 

was the chloro-ansemia. Nothing could be 

The gastric and chiorotic better adapted for their relief than the careful 

symptoms. -l 

attention to the diet and to the surroundings of 
the patient. Fresh air and sunlight, acid fruits, a cheerful room, 
and pleasant society, were useful auxiliaries toward the cure. 
Indeed, as the result proved, nothing could have been more ap- 
propriate than the treatment adopted. The nitric acid was per- 
haps the only remedy capable of correcting the menstrual irregu- 
larity without aggravating the nervous disorder, of intercepting 
the convulsive paroxysms, and of curing the alimentary derange- 
ment. But alone, it was not sufficient to effect a radical cure. 
For, as an intercurrent remedy, the hyoscyamus did the best pos- 
sible service. I hope you will remember this case. 

NITRIC ACID IN UTERINE HAEMORRHAGE. 

Every practitioner of considerable experience has encountered 
cases of metrorrhagia supervening abortion, or that were incident 

to the climacteric, that have resisted all the 
^Metrorrhagia after abor- ordinary means of arrest. The haemorrhage 

has continued for weeks, perhaps, in a passive 
and irregular manner. As a consequence, the patient has been 
greatly reduced and discouraged. There is a loss of appetite, 
headache, malaise, and a series of symptoms that are chargeable 
to the continued drain upon her physical resources. She cannot 
sit upright, or stand erect, but the difficulty is increased. 



566 LECTURES, CLINICAL AND DIDACTIC, 

These cases are very annoying, perplexing, and tedious, and 

sometimes tax our skill to the utmost. Perhaps the various 

astringents have already been tried, but with- 

Nitric add as a demier out ava ii. Or, the more usual and familiar 

ressort. 7 

remedies, such as ipecacuanha, china, secale 
cor., sabina, crocus, hamamelis, trillin or the erechthites, may 
have failed in your hands. In such cases, the nitric acid will 
sometimes answer an excellent purpose. My habit is to give it 
in the second or third decimal attenuation, the dose to be repeated 
every one to three or four hours, according to the urgency of the 
symptoms. 

Case. — In consequence of a rough ride in a sleigh, Mrs. 



aged 28, aborted at the second month. For the first few hours 
she had considerable pain. But the uterine contractions came on 
regularly, and the embryo was soon expelled. Of course, there 
was no well-formed placenta at this early period of pregnancy. 
The post-partum hemorrhage was profuse and long-continued. 
When the pains had ceased the secale which she had been taking 
ceased to have any more influence over the flow. The flow then 
became passive, and the discharge dark-colored and shreddy. 

As the result of keeping her in the horizontal posture, and upon 
the use of an appropriate diet and drinks, she grew better, but 
soon relapsed again. This was twice repeated. The usual reme- 
dies would cause the flow to cease for a little, but upon the least 
change of posture, the discharge commenced again. Matters went 
on thus for nearly four weeks, in all of which time she really had 
gained nothing, but lost much in strength, color and spirits. At 
6 p.m. of Tuesday I prescribed nitric acid in the second decimal 
attenuation, twenty drops in half a glass of water, two teaspoon- 
fuls to be taken each hour. On Wednesday she had had no flow 
since midnight. The same medicine was directed to be repeated 
once in three hours. On Friday there was no return of the dis- 
charge, and she sat up a little. The remedy was discontinued. 
On Sunday she came into the parlor, and afterwards recovered 
rapidly. 

I am aware that there is little in the provings of this remedy 
that is suggestive of its superior efficacy in this variety of haem- 
orrhage ; and also that I am not calling your 

Clinical deductions. ° & J 

attention to anything especially new or strange. 
In general terms, the nitric acid appears to be indicated in those 
hemorrhages from the mucous surfaces which depend upon the 
destruction and desquamation of their investing epithelium. 



ON THE DISEASES OE WOMEN. 567 

Hence we find it useful in passive haemorrhages from the nose, 
the throat, and the respiratory, alimentary and urinary passages. 
The escape of blood by transudation in consequence of the remo- 
val of the protecting envelope, would occasion very different 
symptoms from those proper to an active and alarming haemor- 
rhage, while in the end the result might be equally serious. 

The opinion that the decidua, or outer envelope of the embryo, 
is formed of the mucous membrane that lined the uterus before 
conception, is now very generally received. 
rhage! _menstrual h ^ mor ~ When abortion occurs prior to the third month, 
this lining is stripped off, and the cavity of the 
organ is left as destitute of its proper covering as is the spot 
where the placenta was attached, when that structure is cast off 
in labor at full term. If it is not exfoliated entire, the decidua 
may come away in shreds, in which case the attendant haemor- 
rhage persists for a much longer period, and is passive in charac- 
ter. The blood escapes slowly, and is for some 
speciaiindications for t j me eX p 0S ed to the action of the air before it 

nitric acid. -L 

is expelled from the uterus and vagina. The dis- 
charges resemble those of melaena. Occasionally they are quite 
profuse. In these symptoms, I apprehend, we have the most 
trustworthy and practical indications for this remedy. 

In the case just cited the other remedies failed to give entire 
relief, because the first stage, and the active symptoms to which 
they were appropriate, had already passed. Then it was that the 
nitric acid could be used with the best results. 

Many cases of dysmenorrhcea, more especially of the congestive 

and membranous varieties, merge into menorrhagia. The patient 

suffers extremely in the first stage of the men- 

Postdysmenorrhceai gtmal period. The flow is started with great 

haemorrhage. xr o 

difficulty and prolonged suffering, which is 
similar to the first stage of labor. But when the obstacle to its 
egress is overcome, the pain subsides and the discharge is corre- 
spondingly free and copious. The delay and retention of the 
blood in utero, and the violent efforts to force open the internal 
os uteri, have resulted in the partial or complete exfoliation of 
the endometrium, and therefore, whenever she menstruates, it is 
as if the woman had had a veritable abortion. In one sense the 
haemorrhage is post-partum. In all important pathological re- 



568 LECTURES, CLINICAL AND DIDACTIC, 

spects, it is identical with that which supervenes upon a miscar- 
riage, in the early months of gestation. The detachment and 
disorganization of the uterine mucous membrane develops the 
ease into one of passive haemorrhage, to the relief of which the 
nitric acid is frequently, but not invariably, adapted. 

You are already aware that, at the climacteric, many women 
are liable to protracted haemorrhage, which is apt to be of a pas- 
sive kind, not profuse, but lingering, exhaustive 
Haemorrhage at the an d debilitating. This flow is sometimes in- 

climacteric. o 

tractable. It may or may not contain strips or 
shreds of what are falsely called "pseudo-membranes," but its 
existence often depends upon the morbid condition of the uterine 
mucous membrane of which I have spoken. In some of these 
cases the nitric acid is invaluable. 

Case. — Mrs. , aged 46, had been ill for five weeks with a 

passive haemorrhage, which dated from her last menstrual period. 
She was much reduced in strength, the pulse was weak and irri- 
table, the lips, tongue and alae nasi were very pale. She com- 
plained of occasional faintness, and disgust of food and drinks. 
The feet were cold, and she had almost complete insomnia. Her 
friends thought her going into a rapid decline. Motion aggra- 
vated the flow. Prior to the last period she had a similar attack, 
which continued about four weeks before the flow was arrested. 

I prescribed nitric acid in the second decimal attenuation, to be 
taken as directed in the former case. In two hours the haemor- 
rhage ceased. She made a rapid and complete recovery without 
taking any other remedy. 

In these cases the state of the uterine mucous membrane is 

very analagous to that which we meet with in aphthous conditions 

and incipient ulceration of the alimentary 

Practical conclusions. . . . . _ 

mucous surfaces, as in stomatitis, typhoid lever, 
and in some forms of diarrhoea and dysentery. Here we have a 
similarity of texture, and there can be little doubt that these 
membranes are susceptible to disease-producing and disease-curing 
agents of a similar character. Possibly the sulphuric, phosphoric 
and muriatic acids might also be useful in some cases of uterine 
haemorrhage. The great benefit derived, in the treatment of 
haemorrhages, from citric acid in the form of lemonade and 
oranges, and of tartaric acid in grapes, may not be attributable 
alone to their being grateful to the taste. It is not improbable 



ON THE DISEASES OF WOMEN. 569 

that they are of service in a medicinal as well as in a dietetic 
way. 

CHEONIC CORPOREAL CERVICITIS. CHRONIC CERVICAL METRITIS. 

Case. — Mrs. Emma H. , aged 26, Irish, is of sanguine 

temperament, has had three children and two miscarriages, the 
last of which she induced herself six months ago. The menses 
have always been profuse, and accompanied with great pain. At 
present she complains of pain in the left hypogastric region which, 
at times, extends to the pit of the stomach. She also says she 
has pains through the womb. The bowels are habitually costive. The 
appetite is poor. Micturition is difficult, and the urine carries a 
heavy deposit of urates. She also has leucorrhcea, which is both 
cervical and vaginal. 

Physical examination shows the uterus to be three and a half 
inches in length. The cervix is engorged, thickened and swollen 
in the direction of its circumference. Its diameter measures 
nearly two inches. It is smooth and firm to the touch. The 
introduction of the sound, although not at all difficult, occasioned 
great pain. There is nothing discoverable about the neck of the 
bladder or the urethra to account for the painful micturition. 

She was first placed on belladonna 3 once in two hours. The 
cotton tampon saturated with pure glycerine, was to be intro- 
duced every evening and worn through the night. This treat- 
ment, local and general, promptly relieved the engorgement and 
tumefaction of the uterine cervix, and her general condition was 
very much improved. Since that time, however, she has treated 
herself and our clinical assistants, to a series of hysterical mani- 
festations, of which the following is a list : 

1st. Gastralgia, which continued at intervals for three days. 

2d. Retention of urine — which she passed easily enough when 
left to herself — lasted one week. 

3d. Paralysis of the right arm for three days, and 

4th. Pseudo-pleuritic pains that continued for twenty-four 
hours. 

Our patient was brought into this institution from a neighbor- 
ing hospital where, she says, her case was decided by the phy- 
sician to be one of uterine cancer. I do not credit her story, and 
yet it may be a true one. For excepting what the doctors some- 
times say of each other, no kind of testimony is so unworthy of 
trust as that which patients bring us concerning the views of 
other physicians, and the treatment to which they have already 
been subjected. 



570 LECTURES, CLINICAL AND DIDACTIC, 

Symptoms — This is a case of chronic cervicitis, or of cervical 

hyperplasia. For some reason, most probably on account of the 

abortions which she has suffered, such inter- 

Mechanical symptoms. . . . . 

stitial changes have taken place within the 
uterine neck as to result in its enlargement and hypertrophy. 
Its measurements are very much increased, so that, within the 
pelvis it acts like a foreign body, or a tumor, causing suffering in 
other organs, and making the patient wretched. It presses 
against the urethra in such a manner as to give great pain on 
passing water ; upon the rectum so as to cause the bowels to be 
obstinately bound ; and is sufficient to maintain a constant leu- 
corrhceal flow. 

Other symptoms which usually attend upon this affection are 
pelvic and sacral pains ; prolapse of the womb, which is dragged 

toward the vulva by the increased weight of 

Direct and reflex symptoms. . 

its lower segment; dyspeptic troubles, as 
vomiting, loss of appetite, gastralgia, loathing of food and caprices 
of appetite ; and inability to walk without great effort, pain and 
fatigue. The incidental nervous disorders are more prominent 
than characteristic. Hysterical symptoms are an almost certain 
outgrowth of this particular lesion. Reflex ovarian irritation is 
also very common, and pains in the left hypogastrium, such as 
this woman complains of, are almost always present. 

Menstrual disorders are frequent. Some of these patients have 

amenorrhea. In many cases there is unusual pain and difficulty 

in the commencement of the "period," which 

Menstrual disorders. . • -i i • i i r 

is occasioned by a partial closure of the cervico- 
uterine canal. But when that obstacle is overcome, the cervix 
being so very much engorged, the flow becomes excessive and 
perhaps long-continued. It often arises from excessive or impro- 
per exercise or travel at the month. 

The neck of the womb is so tender to the touch that sexual 

intercourse is intolerable. In some cases of insuperable aversion 

to the act, which you will meet with in private 

Contact. , .. . . p 

practice, you will find that this condition ol 
the cervix exists. Many patients with this form of cervicitis 
complain of burning pain within the pelvis. This pain is usually 
aggravated by exercise, as in standing, riding or walking. With 
those who are obliged to be upon their feet, the friction of 



OX THE DISEASES OF WOMEN. 571 

the swollen cervix against the vaginal walls sometimes occasions 
extensive ulceration of its investing mucous membrane. 

Nature and Cause. — This disease consists essentially in a 
lrypertrophy of the cellular tissue of the uterine cervix. And 
this hypertrophy, or hyperplasia, as Dr. 
Thomas prefers to style it, almost never occurs 
excepting in those who have been pregnant. It is a post-puer- 
peral affair. It may follow delivery at term, but is more likely to 
result from an arrest of development consequent upon abortion. 
In many cases it supervenes the artificial induction of miscar- 
riage, the traumatic injury sustained seeming to add to the risk 
of its resulting as a sequel. 

It may be either the cause or the consequence of dysmenor- 
rhea. In " bilious climates" it is indirectly connected with 
hepatic disease. In this class of cases the 

From bilious complication. . • . 

uterus acts as a diverticulum for the blood which 
should circulate more actively through the portal system. The 
connective tissue of the cervix becomes engorged, and an exces- 
sive development of the uterine neck is the consequence. The 
cause acts and re-acts. You will be on the alert for this condi- 
tion of things among multiparas in malarious districts. 

Diagnosis. — A few symptoms, carefully considered, will gener- 
ally enable us to differentiate between this disease and cancer of 

the uterine neck, which is usually of the scir- 

From uterine cancer. . 

rhous variety. 1 am pretty confident that, in 
this case, the swelling of the cervix is not due to scirrhous de- 
posit, because it is smooth and regular in outline and feels like a 
fibrous tissue. If it were cancerous, the outline would be irregu- 
lar, nodulated, and bosselated, and it would feel hard and carti- 
laginous. Cervical metritis is almost always a sequel to preg- 
nancy and to labor. It bears no especial relation to the climacteric. 
Cervical cancer is not at all infrequent in nulliparae, and is most 
common at the "change of life." In the former, no matter how 
much the organ is swollen or displaced, it is mobile. In the 
latter, it may be fixed and immovable. In cervical metritis there 
is no evidence of a particular cachexy, while in cervical cancer 
such a dyscrasia is, sooner or later, manifest. In cervicitis there 
is no tendency to deep-seated ulceration, with destruction of 



0<2 LECTURES, CLINICAL AND DIDACTIC, 

tissue and haemorrhage ; in cancer, such a tendency is very 
marked. 

But, even with the greatest care, it is not always possible to 

distinguish between these two diseases, more especially in the 

non-ulcerated state of uterine cancer. I have 

A new diagnostic test. . . 

several times resorted to an expedient that has 
helped me to settle the diagnosis between them. You will do no 
harm by trying it. It is simply to use the cotton tampon satu- 
rated with pure glycerine, just as it was employed in this case. 
If the enlargement is due to plain, uncomplicated cervicitis, the 
depletion by means of the glycerine will soon lessen the size of 
the uterine cervix very perceptibly. If, however, the swollen 
state of the cervix arises from cancerous inflltiation, or from an 
interstitial fibroid, the glycerine will not sensibly diminish its 
bulk. If this simple test had been applied in the case before us, 
my unknown predecessor would not have decided this to be a 
case of uterine cancer ; for now the cervix is nearly normal both 
in size and texture. 

The increased depth of the womb, the liability to haemorrhage, 
to endometritis, to uterine displacements, and to coincident peri- 
tonitis, which belong to chronic corporeal me- 
raSrk?r 05is fr ° m corporeal tritis, and not to corporeal cervicitis, will 
serve to separate these two diseases. In some 
cases they succeed each other, and again they co-exist. 

Prognosis. — This disease may continue indefinitely. Its course 
and termination will depend upon the nature and severity of the 
disorders with which it is complicated. It may decline at the 
climacteric, or possibly develop into a more serious form of or- 
ganic disease. In a reflex manner it may cause the gravest lesions 
of the heart, the lungs, or of the nervous centers. Frequent 
abortions render it more chronic and intractable. If the patient 
is ill in other respects and incapacitated from exercise, the cure 
is more doubtful. 

Treatment. — It is quite as important to prescribe the proper 

posture for this class of patients as it is in case of acute cervical 

metritis.* Keep them in a horizontal or reclin- 

Postural treatment. . .. __ ,, . n ,, ,-, 

mg posture, and off their feet, at the month 
especially. Shopping, visiting, party-going are as injurious as a 

* See page 277. 



ON THE DISEASES OF WOMEN. Did 

journey by rail, or an excursion on horseback. Such a patient 
should let her sewing-machine rest, and her servants take care of 
themselves. 

If there is obstructive dysmenorrhoea, remove the cause and 
relieve the consequent engorgement of the cervix. If she has 
intermenstrual dysmenorrhoea, cure it. If the 
flow is too scanty, try and prompt it to be more 
free. If the rectum is paralyzed, or the bowels are badly consti- 
pated, she may be relieved when these conditions are set aside. 
She should be especially careful not to do anything before, during 
or directly after the flow that can by any possibility complicate 
the case and increase the cervical hypertrophy. 

If there are " bilious " symptoms remember that they are likely 
to afford the most prominent and cardinal indications for the rem- 
edy or remedies. Podophyllin, mercurius, chamomilla, bryonia, 
nux vomica, china, natrum mur., nitric or nitro-muriatic acid, or 
some similar remedy, may be specifically called for. 

Other remedies that I have found especially useful are bella- 
donna, lachesis and apis mellifica. Some of the 

Bell., lach. and apis. x _ 

best cures that I have ever made have been 
performed with these three remedies in this class of cases. 

Locally the same treatment as already recommended for the 
acute form of this disease is equally suited to the chronic vari- 
ety.* The cotton tampon saturated with glyc- 

Local adjuvants. . . 

erme can do no possible harm, will not interfere 
with the action of internal remedies, and may do a positive good. 
After the first application it can be prepared, introduced and re- 
moved by the nurse or the patient herself. I generally recom- 
mend that it shall be used two or three times per week, according 
to circumstances. 

* See page 278. 



574 LECTURES, CLINICAL AND DIDACTIC, 



LECTURE XXXIV 



vascular tumor of the meatus urinarius. 

Gentlemen : 

The refined and cultivated physician is sometimes at a loss to 
know when it is best to propose, and to insist upon the necessity 
for a physical examination of the female generative organs. He 
will not pander to the vulgar habit of resorting to this measure 
almost indiscriminately ; while, for the sake of his patient's wel- 
fare, as well as of his own reputation as a skillful diagnostician 
and practitioner, he must not postpone it too long, neither neg- 
lect it entirely. So important is this matter that a physician's 
reputation is sometimes made or ruined by the rumor that he is in 
the habit of using the speculum on the slightest pretext, or that 
he is opposed to its employment altogether. 

I am led to these reflections in consequence of the examination 
Avhich I have just made of a case in the ante-room. This case 
had been attended by two physicians, one of whom pretended to 
have made a proper " examination" of the patient, while she 
refused to allow the other to do so. Both were wrong in their 
conclusions, and, consequently, neither of them did the patient 
any good. 

Case. — Mrs. T , 30 years of age, the mother of two child- 
ren, the youngest of which is four years old, has been in poor 
health for twelve months. One year ago she got her feet wet 
while menstruating. She has not been well since. Prior to that 
date her menstruation had always been regular ; but since that 
sudden check of the flow, the periods have returned every three 
weeks. There is no pain, but from time to time the flow is 
becoming more scanty. 

Soon after the taking cold she began to have trouble in passing 
water. The inclination to urinate was very frequent, and some- 
times quite irresistible. It was aggravated by being much upon the 
feet. Anxiety of mind, sudden good or bad news, and excite- 



ON THE DISEASES OF WOMEN. 575 

ment of any kind would induce a paroxysm. At first, but only 
for a short time, the urine was copious and colorless, but for many 
months it has been perfectly natural in quantity and quality. 
The only exception to this rule is that it has, once or twice, been 
a very little bloody. 

The only real pain experienced is after the flow of urine, or 
rather, while the last drops are running away. This induces a 
burning, stinging pain, which is peculiar, and " very dreadful," to 
her. Walking is painful, and, for some reason which she can not 
explain, intercourse occasions the most excruciating suffering. 

The first physician who treated her for this difficulty made an 
examination with the speculum, and after analyzing all the symp- 
toms that were gathered, pronounced her to be suffering from 
"disease of the kidneys." After some months of treatment with 
no especial reference either to the menstrual or the urethral diffi- 
culties, she changed her physician for one of more intelligence 
and experience. 

Her second physician prescribed for her for a time, and then 
requested permission to make an examination with the speculum. 
But it was denied, and he continued to treat her for " disease of 
the womb." 

The physical examination just made discloses a vascular tumor 
which is nearly the size of my thumb-nail, at and within the 
mouth of the urethra. It is very tender to the touch, and of a 
cherry-red color. The urethra around and beyond it is tumefied 
and evidently somewhat inflamed. The womb is in situ, and the 
os uteri has a healthy appearance. 

These vascular tumors, which are not at all infrequent, are 

very troublesome and often give rise to much suffering. They 

are located just at the mouth of the urethra, 

Nature and location. ,.,.. i i • iii i 

and within its canal, being attached thereto by 
a pedicle, like a polypus. They consist of a hypertrophy of the 
mucous papillae, and are very vascular. Sometimes the tumor is 
lobulated ; more rarely there are two instead of one. The pedicle 
may be so slender as to break very readily when you seize the 
growth with a pair of small forceps ; or it may be firm and un- 
yielding. 

The symptoms accompan\dng such a case have already been 
detailed in this report. Painful and frequent micturition, espe- 
cially after exercise upon the feet ; pain upon 

Symptoms. , _ , _ _ 

walking, intolerance of coitus, and the most 
peculiar and exquisite suffering with the passage of the last drops 
of urine, are almost pathognomonic. These symptoms may eon- 



576 LECTURES, CLIXICAL AND DIDACTIC, 

tinue until the patient is very weak and irritable. But the diag- 
nosis can not be made with certainty except by a physical 
examination of the parts involved. Indeed this examination must 
be visual, for unless you see the tumor, you can not be certain of 
its existence. 

The question recurs upon the necessity for such an examina- 
tion. This woman, who lives within a stone's throw of the 

hospital, has suffered for twelve months when 
exam'inlfSn^ physical sne niight have been relieved in as many 

minutes. But two things were in the way of 
her getting well so speedily. The first was the ignorance of the 
doctor who examined her with a uterine speculum, and reported 

that she had " disease of the kidneys." How 
obstacles to recovery in ^g instrument could aid in the diagnosis of 

this case. t> 

renal disease, and what particular affection of 
the kidneys she was thought to have, I do not know. 

The second obstacle was her own shrinking sensitiveness, 
which would not permit the other physician (who was compet- 
ent) to do as he thought best. And so she has failed to obtain 
the hoped-for relief. 

How shall you act in similar cases ? The best rule that I can 
suggest is that you wait a reasonable length of time, providing 
the s}*mptoms are not very urgent. Give the 
to^h% r c5 U expiofation Sort appropriate remedies meanwhile, and place the 
patient under such hygienic regulations as will 
favor her recovery. But if the symptoms do not yield as they 
should, or if they show a decided tendency to relapse, the infer- 
ence will be that there is a local cause which perpetuates 
the mischief, and prevents a radical cure by internal means, alone. 
Under such circumstances a few sensible and cogent reasons 
addressed to the patient, will satisfy her of the necessity of a 
local examination, and obtain her consent thereto. You can 
explain the case by sa}~ing that the persistence of the symptoms 
and their liability to return when they have been relieved, leads 
} t ou to conclude that they do not afford a reliable criterion of the 
nature of her disease. And, above all things, assure her before- 
hand that you will on no account proceed to operative interfer- 
ence, until the case is fully understood by both parties. 

This plan is as appropriate in a case in which the symptoms 



ON THE DISEASES OF WOMEN. 577 

are connected with urination, where the quality of the urine is 
unaltered, as 'it is in case of chronic and invet- 
aMffigSSS: erate ferine disease. For you may be morally 
certain that when you have given cantharis, 
mercurius, aconite, apis mel., cannabis, hyoscyamus, and kindred 
remedies, under appropriate indications, and relief has not fol- 
lowed, that the case needs a local examination, and perhaps 
topical treatment also. 

Treatment. — Excision is the remedy. You may seize the growth 

with a pair of delicate forceps, and snip it off with a pair of sharp 

scissors, or the bistoury. Or ligation, or as- 

Excision. . 

trmgents and cauterization may answer; but 
they are more slow and painful. The stump, or point of attach- 
ment^ may be touched with the per-chloride of iron, or with a 
stick of the nitrate of silver, in case of hsemorrhage. In order to 
prevent the subsequent growth of the tumor it may be necessary 
to repeat the application of the caustic after a few days. 

The after treatment consists in keeping her in the horizontal 
posture for twenty -four hours or more, in order to avoid consecu- 
tive inflammation. If there are any signs of 

After-treatment. ,..., , , -, '.-,, 

urethritis, it should then be treated as 11 the 
case were an idiopathic one.* 



LATERO-FLEXION OF THE UTERUS. 

Case. — Mrs. , aged 51, of nervo-bilious temperament, was 

admitted to the hospital one month ago. She has been suffering 
more or less for ten years with uterine difficulties. At 40 years 
of age she was treated locally for ulceration of the os uteri, and 
cured. She has had three children, the last of which is 16 years 
old. She passed the climacteric eight months ago without accident, 
and attributes her present troubles to having to ascend and descend 
three flights of stairs at her boarding place last winter. 

She complains of pain in the back and a sense of dragging 
down in the pelvis, profuse vaginal leucorrhcea, and a burn- 
ing pain in the right inguinal region. The last symptom, how- 
ever, is not constant. She can not lie upon her left side. The 
right leg is at times numb and almost paralyzed. The bowels are 
tolerably regular, the appetite is not very good, the urine is 
normal. 

Physical examination reveals a right latero-flexion of the womb* 

37 *See page iSi. 



578 LECTUEES, CLINICAL AND DIDACTIC, 

the body of the organ being apparently adherent to the right wall 
of the pelvic cavity. This deviation of the uterus was corrected 
Dy means of the sound, which, together with a few doses of mix 
vomica 3rd, promptly relieved the paralytic feeling in the right 
limb. The patient was ordered to lie on the left or opposite side, 
and upon the back exclusively. Subsequently she took the citrate 
of iron and strychnine in the third decimal trituration, a dose 
every three hours. 

Cases of latero-flexion are comparatively rare. Nonat met 

with it in but one out of 339 examples of uterine displacement. 

As in other flexions of the organ the cer- 

Relative frequency of. . .. . r 

vix is but slightly, it at all displaced, while 
the body is more or less curved upon its neck. The pain and 
distress are usually referred to one side or the other of the 
pelvis. The womb inclines more frequently to the right than 
to the left side, probably because in a majority of cases it has 

taken that direction during pregnancy. In 

Causes. . >i i i i ■ 

some ot these cases it is possible that the invo- 
lution of the womb after delivery may be less complete in the 
right or dependent part of the organ, and that, consequently, its 
increased weight may cause it to topple over in that direction. 
Occasionally it is said to follow as a sequel of chronic metritis, 
and also of constipation with paralysis and a stuffed condition of 
the rectum. It may occur in a woman who, being confined to her 
couch, persists in lying day and night, always, upon one side of 
the body. Or it may be displaced laterally by direct pressure 
from uterine and ovarian tumors, peri-uterine deposits and pelvic 
abscess. 

The symptoms are not distinctive. Most patients complain of 
burning pains in the iliac or the inguinal regions, which pains are 

severe and protracted, and extend more or less 

Symptoms. . . . 

into the corresponding hip and thigh m pro- 
portion as the nerves are pressed upon mechanically, and the free 
distribution of the nervous currents is interfered with. Inability 
to lie on the opposite or sound side is suggestive, although not by 
any means pathognomonic of this particular variety of uterine 
deviation. 

It is only by the introduction of the sound that we can be quite 
positive in our diagnosis. If, after being passed as far as the 



ON THE DISEASES OF WOMZN. 579 

internal os uteri, the point shall enter the organ and then travel 
towards the right or left acetabulum, the con- 
cavity of the instrument looking to the corres- 
ponding limb of the patient, it is safe to conclude that she has a 
lateral deviation of the womb. If the direction of the sound is 
changed when she turns over and lies for a little on the opposite 
side, the displacement is not a very serious affair. 

1 have now passed the sound to the fundus uteri. You will 
observe that the roughened surface of the handle, which corres- 
ponds to the tip of the instrument, and its 

Passing the sound. . -i i • -i -i • -i p 

anterior curve, looks towards the right thigh of 
the patient. And although, as I have told you, the sound is of 
little use as a means of repositing the organ, still in these cases 
of lateral displacement, and with proper precautions, it may be 
of service in this way. While she is lying upon the opposite side 
therefore, so that gravity may assist us, we gradually turn the 
sound, and the uterus along with it, until its pelvic curve or 
concavity looks towards the symphysis pubis. 

Now the organ is in situ, and the sound has served the double 

purpose of acquainting us with the precise 

nature of the displacement, and of furnishing 
us with a means for its reduction. 

The treatment of such a case as this is very simple. The first 
indication, after having put the organ in place again, is to select a 

proper posture for the patient. Manifestly she 

Postural treatment. "I. 7 .-,. 

should lie on the opposite side, in order to keep 
the womb from gravitating into its unnatural position. This woman 
had right latero-flexion, in which the fundus uteri had toppled 
over against the right side of the pelvis. She must therefore lie 
upon her left side, if she wants to get well of this difficulty. 
There will be no harm in her turning upon the back occasionally, 
but she should not permit herself to lie upon the right side for 
months to come. 

This will be a difficult prescription to take. For the first 
few days especially, it will require some moral courage to carry 

out those instructions faithfully. She will 

Need of courage. ii-ii ••ii-i-' 

probably have pain m both hips, aching and 
unrest in consequence. She may lose her appetite, pass sleepless 
nights, and, altogether, feel worse for a time than when she came 



580 LECTURES, CLINICAL AND DIDACTIC, 

to the hospital. But ultimately her sufferings will be relieved, 
and she will be glad of her good resolution. 

These cases are more readily and radically cured than what is 
known as latero-version, a condition in which the uterus is 
directly across the vagina, with the fundus at one acetabulum, 
and the cervix uteri at the other. 

If the uterus has been flexed laterally for a considerable time, 
it may be so bound down by unnatural adhesions that its reposi- 
tion will be followed by more or less of peri- 

Contingent diseases. . ... .,, P -■ 

toneal inflammation. Again it will be followed 
by a species of sciatica, which is persistent and troublesome. For 
the former, such remedies as rhus toxicodendron, belladonna, or 
bryonia, may be required. For the latter, I know of nothing to 
compare with colocynth. 

SPINAL IRRITATION, WITH AMENORRHEA, VICARIOUS VOMITING 
AND CONVULSIONS. 

I was consulted in the following case by my friend, Dr. Wm. 
D. Foster, of Hannibal, Mo. The notes thereof were furnished 
by the patient, who is a most estimable and intelligent person : 

Case. — My parents were born in Vermont, and up to within a 
short period before their death, were very healthy and robust. 
With my mother the " turn of life " came at 53. This caused a 
severe illness, which developed into insanity, and finally termin- 
ated in death from heart disease. My father lived to be 68, and 
died of dropsy of the heart. I was born in Cleveland, Ohio, and, 
when my mother died, was 14 years of age. While visiting Chi- 
cago the same season, I had a severe illness, of which I remember 
nothing, excepting that I had a very sore mouth. Previous to 
this illness, I had always been very well, except that when I was 
about seven years old I was vaccinated, and it made me very sick. 
I lost the use of my left arm for some time ; had swellings in the 
arm-pit and upon the arm, which had to be lanced. 

In the spring of 1862, the corner of a falling door struck me 
between the shoulders, and left me insensible for a day or two. 
Upon recovery I could not see out of my right eye. It did not 
pain me much until I began to recover my sight, which was sev- 
eral months after the accident. Often since that time I have 
been troubled with very severe pains in that eye. At these times 
the pupil enlarges, and I can not see out of it. 

Soon after my illness in Chicago I realized that there was some- 



ON THE DISEASES OF WOMEN. 581 

thing wrong with my spine. The physicians predicted that I 
would outgrow it. The pains in the back were almost constant, 
but were very much aggravated whenever there were signs of 
torpidity of the liver, which generally occurred two or three 
times a year. Sometimes I would be prostrated with these 
attacks for from two to four weeks. 

In 1864, 1 was troubled with the passage of gall-stones. Every 
few days I would suddenly be prostrated with dreadful pains in 
my side, which would last for several hours. These attacks de- 
veloped into such a derangement of the stomach that it would 
not retain food. The pain finally became constant, and I was 
seriously ill for about six weeks ; was confined to the bed, my 
back and head troubling me greatly. Prior to this, the worst 
pains in my back were between the shoulders, extending upwards 
to the head, and so severe as often to make me delirious for a 
few hours. 

In 1865, I had several abscesses, which were thought to have 
been caused by my having fallen down stairs. These abscesses 
are now believed to have formed in the left ovary. I had no 
more of them until about a year ago, but within a year have had 
several, all of which have been on the right instead of the left 
side. They have discharged through the vagina. 

I always had more or less headache during my "periods." For 
the last five years have had considerable pain in the small of my 
back, and in the womb itself. In the winter of 1867, I think it 
was, I was laid up for several weeks with lameness in the small 
of the back, could not move without help, and for some time there 
was no action of the bladder, the urine being retained. From 
that time until now I have suffered from scanty and irregular 
menstruation. The flow finally stopped entirely, and I suffered 
each month with pain, violent crampings, etc. 

I was married in 1860, at the age of 21 ; always menstruated 
properly until the time aforesaid, excepting about four months in 
the year 1859, when, for some unknown reason, my courses 
stopped. I did not, however, suffer much on account of it. My 
back always pains me somewhat, but when the different organs 
named are in a proper condition, I suffer no serious inconvenience 
from it. 

This statement shows, in very graphic outline, the chief points 
of interest in this case. But there a-re additional symptoms which 
our patient could not catalogue. 

For two years past, whenever the menses have been arrested, 
scanty, or tardy in their appearance, she has had 

Vicarious hsematemesis. . , _ . 1 

vomiting ot blood. 11ns naematemesis never 
comes excepting at the month, is not very copious, nor is it 



582 LECTURES, CLINICAL AND DIDACTIC, 

accompanied or followed by any evidences of inflammation or 
of other organic disease of the stomach. 

She is also subject to periodical attacks of severe pain in the 

back and head, which end in spasms, delirium, and finally in 

clonic spasms of the muscles of the back, with 

Convulsions. 1 .. . 

opisthotonos and ieariul convulsions 01 all the 
voluntary muscles. Concerning these paroxysms, which are even 
more painful to her friends than to herself, the Doctor says ; "I 
have observed that the cramps, delirium, dilatation of the right 

pupil, pains in the spine, etc., invariably come 

The causes of. .. . .. . __ 

on when there is any dimculty with the liver. 
The menstrual approach excites the same train of symptoms. So 
also does any mental trouble, disappointment, or other cause of 
serious mental excitement. 

" The sensitiveness of the spine is most marked in the lower cer- 
vical and upper dorsal regions. The spine, however, is somewhat 
sensitive throughout. She frequently falls to the 

Prodromata. 1 . . 

floor ; but, when she has any premonition, usu- 
ally gets to a chair or lounge, and saves herself. These spells 
usually follow the more severe symptoms of spinal irritation. She 
has never been pregnant." 

The patient came to this city, and was under my care for sev- 
eral weeks. Her case was interesting and intricate, for several 
theories of her disease suggested themselves. 
Theories concerning the jj er illnesss might be said to have dated from 

nature of the disease. o 

her vaccination ; or to have been caused by the 
traumatic injury of the spine from the falling door, and from fall- 
ing down stairs (spinal irritation) ; to the hepatic complication ; 
the menstrual irregularity and suffering ; or to the epileptiform 
nature of the paroxysms. But the history of the case led us to 
infer that these causes had acted conjointly, or rather consecu- 
tively, to produce so complicated a set of symptoms. 

My friend, the Doctor, had faithfully applied the most appro- 
priate remedies for the relief of the individual and collective 

symptoms, but without any real or lasting bene- 
remedfil 7 ' m the "* ° f fit - I n tnis treatment he had persisted for 

more than two years. The menstrual derange- 
ment being marked and prominent, we concluded that it must be 
an important factor in the case. In his letter, the Doctor said : 



ON THE DISEASES OF WOMEN. OO'd 

" The non-appearance of the menses and the scant flow have been 

invariably owing to the spasmodic closure of the uterine cervix. 

Whenever I have succeeded in passing a tent 

Cause of the menstrual w ithin the internal os uteri, the flow proceeded 

disorder. 7 *■ 

properly. But the introduction of that instru- 
ment was a proceeding in which I think there were more failures 
than successes. By the use of Atlee's dilator, however, I could 
accomplish the purpose with much greater certainty." 

Dilatation was therefore persevered with so as, if possible, to over- 
come the spasmodic closure of the cervix and to secure a free and 
easv flow of the menses. If this end were obtain- 

Failure of dilatation. *• . tit -i • 

ed, it was thought the result would be to bring 
relief to the nervous centers that were surcharged with blood — the 
patient being very fleshy and of full habit. But this means failed 
because of the persistent inclination to spasm of the uterine neck. 
For almost as soon as the tent, or Priestly's dilator, had been re- 
moved, the cervix would shut so tightly that it would be next to 
impossible to pass the sound. 

We accordingly determined upon incision. The Doctor came 
to town and assisted me in the operation. I performed the bi- 
lateral section with a Simpson's hysterotome, 
The operation of incision } mt ^id not cut the wall of the cervix entirely 

oi the cervix. <J 

through, as recommended by Sims, and prac- 
ticed by my friend Comstock. The haemorrhage, which was not 
severe, was arrested by a cervical tampon that had been saturated 
with the tincture of the per-chloride of iron. The patient was 
kept in bed for one week only, the cervix being dilated every al- 
ternate day with Priestly's dilator, to prevent atresia of its 
canal. 

She soon returned home, and with the occasional passage of the 

sound, and of the dilator (which are introduced without difficulty 

since the operation of incision), she mcnstru- 

Subsequent history. 

ates more regularly and copiously than she has 
done for a long time. Thus far she has had no more vomiting of 
blood. In other respects, also, her health is somewhat improved. 
The convulsive paroxysms are less frequent than they were. 
Their character and severity, however, are unchanged. The cer- 
vical and dorsal pains continue. The dilatation of the pupil and 
the temporary amaurosis are relatively infrequent of late, but 



58-i LECTURES, CLINICAL AND DIDACTIC, 

when they are present they have the same characters as before. 
This patient is therefore still under treatment. 

Now, gentlemen, I have brought this case to your notice for the 
sake of illustrating three very important points, viz. : (1.) That 
in your daily experience as practitioners, you 
will discover that the diseases of women are 
often more complicated than you had supposed they could be ; 
(2) that Uterine Surgery, and Uterine Therapeutics are by no 
means perfect and infallible ; and (3) that, in this as in some 
other departments of our art, rapid and brilliant cures are the 
exception and not the rule. 

If clinical teachers were always faithful to their trust, and if 

those who report their experience in our societies and journals 

.. . always told the plain, unvarnished truth, such 

A fallacious idea. tip i i • i • i • 

cardinal facts need not be mentioned m this 
connection. But it is not so. Students are often led to believe 
that nosological distinctions are real, and that diseases run an 
uncomplicated and unvarying course. If they have little knowl- 
edge of human nature and of human frailties, and especially if 
they have seen but little of the " practice," they are decidedly 
impressed with this idea. But the illusion vanishes when they 
are brought face to face with disease. And I have sometimes 
thought that they are more likely to be undeceived in this respect 
in treating the diseases that are peculiar to women, than in their 
experience with any other class of ailments. This is a case in 
point. 

It is so easy to dictate and dogmatize in these matters that one 
might prescribe a manual operation, or an internal remedy for 

such a patient, and insist that either of them 
mSiane. tlc surgery and should effect a cure. But you will find that 

these very complicated cases are not so easily 
disposed of. A certain operation, or a single remedy, may need 
to be modified or changed repeatedly, perhaps, before the 
cure is effected, if indeed it ever is. The incision of the cervix 
uteri in this case was of real service. It is a great point gained 
to have secured the regularity and freedom of the menstrual flow, 
and more than all, to have put a period to the hsematemesis before 
any manifest organic disease of the stomach had supervened. 
But the operation has not cured the woman at all. And it 



ON THE DISEASES OF WOMEN. 585 

would be wrong for me to report her as well again, when she 
is not. 

There are those who will tell you that this or that remedy, in a 

particular potency, would undoubtedly have cured her. But 

such an opinion is presumptuous. We can 

Do not claim too much. ttti 

accomplish much with our remedies. When 
fitly chosen they are wonderfully efficacious. Every year their 
curative scope is widened, and their clinical range more accu- 
rately defined. But, although we can accomplish more than our 
predecessors ever did, and with means that they deemed too insig- 
nificant to be of any practical use, we should not claim that our 
skill and success are unbounded. If we are unreasonably confi- 
dent we defeat our purpose and disgrace our calling. 

The health of woman is exposed to so many vicissitudes, and 
she is the victim of so many interior sources of mischief, that you 

will always do well to qualify your prognosis 

Qualify your promises. . 

and your promises to cure her, even ot the 
simplest ailment. Especially should you forbear from engaging 
to restore her rapidly to a good state of health, in case of any 

disorder of menstruation or of the nervous 

Case 

system. I once heard a physician claim that a 
single dose of sepia had entirely cured one of his patients of a 
long-standing and serious dysmenorrhoea. It had cut short her 
suffering and relieved her like magic. This last result we were 
prepared to credit ; but, when he went on to say that the pre- 
scription had been made only a fortnight before, and that the men- 
strual cycle had not yet returned, every experienced person pres- 
ent knew just what to think of the rapid and radical cure which, 
in all probability, had not been effected. 

VTJLYO-VAGINITIS. — PRURIGENOUS VULVITIS. 

Case. — Mrs. T , aged 45, English, married and the mother 

of eight children, was admitted to the hospital yesterday. She 
has never had a miscarriage. Three years ago she was troubled 
with a sudden arrest of the menses, which continued for eight 
months. They finally came on again spontaneously, and in the 
usual quantity, but the flow was subsequently attended with 
considerable pain. The climacteric was passed without any 
untoward symptoms one year ago. 



586 LECTURES, CLINICAL AND DIDACTIC, 

During the period of arrest of the catamenia, this patient was 
treated for ulceration of the womb, which, she says, was accom- 
panied by considerable discharge. At one time she remembers a 
sudden flow of " matter " which, she thinks, amounted in all to 
nearly or quite a tea-cup full. This discharge came suddenly 
ik like the waters/' There has been no trouble in micturition. 
The bowels have been constipated, and she has been annoyed with 
internal hemorrhoids which occasionally bleed. 

At present she complains of intense itching of the genitals, and 
says that pimples sometimes form on the labia and then burst. 
There is heat in the vagina, especially after exercise, and occa- 
sionally a slight, but never a copious, leucorrhcea. 

She also has considerable pain in the right leg, which extends 
from the right iliac region in front, around and over the hip, and 
down the limb to the inner malleolus and the inside of the foot. 
This pain is not affected by changes of weather, but is aggravated 
by motion. The right knee-joint is enlarged, as in chronic 
synovitis. 

On physical examination the uterus was found in position, and 
of normal size. Examination with the speculum revealed the 
mucous membrane lining the vagina and reflected over the vaginal 
portion of the cervix to be studded with a papulous eruption 
resembling prurigo. The same eruption extends over the vulva 
and the adjacent integuments. 

This, gentlemen, is one of the old-fashioned women, whose 
maternal record is in every respect a creditable one. She has 

borne eight children, and has never suffered a 

miscarriage. If it were possible, I would take 
occasion to name all the physical and moral exemptions that she 
has enjoyed in consequence. Not the least among them is that 
she has escaped any serious illness at the climacteric. 

Three years ago, at the age of 42, she had suppression of the 
menses for eight months. Meanwhile she received treatment for 

ulceration of the womb, but whether she ever 
tbn Srethe chlng™*" nad tnat Cliseas e, we do not know. It is very 

probable that her physician mistook the sup- 
pression for a sign of ulceration, and proceeded to ' cauterize her 
with a view to restore the catamenia! flow. It is equally proba- 
ble that the menstrual arrest was due to a physiological and not 
to a morbific cause, or in other words, that it was a sign of the 
approach of the "change of life;" for, as I have already said, 
such intermissions in the performance of this function are by no 



An exceptional case. 



ON THE DISEASES OF WOMEN. 58T 

means rare in women who have reached their fortieth year, and 
iii whom the period for its entire cessation can not be very dis- 
tant. 

The probable cause for such a temporary arrest, and which is 

apt to be overlooked, is a failure in the ripening of the ovule, 

and in the dehiscence of the Graafian follicle. 

Defective ovulation. . _ , 

By-and-by the function 01 ovulation is resumed 
and the menstrual flow re-appears. 

The muco-purulent discharge of which she speaks may have 
been due to a vicarious accumulation and retention within 

the uterine cavity, which finally found vent 

with the suddenness of a rupture of the bag of 
waters. She could not have had an abscess without previous 
local pain and suffering, and general constitutional symptoms, of 
which she makes no mention. 

Constipation is the rule in similar cases, and a woman at 45, 
who has had eight children, can hardly have escaped haemor- 
rhoids. Concerning the latter I have questioned her carefully, 
and find that they are not inveterate. 

This prurigenous eruption is always accompanied by a loss of 
rest and sleep, constant irritation and distress. It is very apt to 

become chronic. The heat of the parts, and 

Symptoms. . . 

the torment sometimes occasioned by walking, 
sitting, intercourse, and physical exercise of every kind, are 
almost insupportable. If the characteristic peculiarities of the 
eruption have not been destroyed by the scratching and rubbing 
of the parts to which the poor victim is compelled to resort, the 
papulae resemble those of prurigo when it is seated on other 
parts of the body, as, for example, the neck, shoulders, back and 

outer surfaces of the extremities. So much of 

The eruption. . 

it as is located upon the cutaneous surface of 
the labia, the perineum, and even about the anus, may be color- 
less and invisible, but if the parts have been wounded by fric- 
tion, you may perhaps find little black scabs scattered here and 
there. Sometimes, as in this case, there are occasional vesicles 
and wheals, which are readily discharged. 

On the mucous side of the raphe and within the vagina, Iioav- 
ever, the color of the eruption differs from that of the surface 
upon which the papulae are located. This is especially true in 



588 LECTURES, CLINICAL AND DIDACTIC, 

the case of elderly women in whom there is no diffuse vaginitis, 
and whose vaginal mucous membrane has not 

The color of. .. .. . 

recently been discolored either by pregnancy 
or menstruation. But, in younger persons, in whom the opposite 
condition of this membrane prevails, there would be very little 
difference in hue between them. 

The causes of this peculiar affection are really unknown. It 
has been ascribed to various infractions of the rules of hygiene, 

such as the eating of unwholesome food, and 

the lack of proper clothing, cleanliness and 
exercise, to sexual excesses, to the change of life, and to the non- 
elimination by the proper emunctories of certain impurities from 
the blood. It may alternate with chronic skin disease. 

There is a form of granular vaginitis from which pregnant 
women sometimes suffer that should not be confounded with this. 

In it the eruption, or rather the pin-head pim- 
va D inms° sIs from granular pies, consists of myriads of little granulations 

which give rise to pain, heat, and sometimes 
to considerable discharge. It is self-limited, is not accompanied 
by vulvar prurigo, and terminates with delivery. 

Prurigenous vulvitis, of which this is an example, can be dis- 
tinguished from the follicular variety by the fact that in the latter 

the lesion is limited to the follicles which are 

From follicular vulvitis. n . . . 

lound upon the vulva, and just within the 
ostium vaginas. These follicles become inflamed and finally dis- 
charge a purulent or muco-purulent secretion which, in many 
cases, may be seen exuding from the mouths of the separate folli- 
cles. But these diseases often co-exist. Follicular vulvitis is also 
incident to gestation, and may occur as a contingent or sequel of 
the eruptive fevers, and of diphtheria. More frequently, how- 
ever, it is due to a very depraved and vitiated habit. Sometimes 
it is a sequel of gonorrhoeal inflammation. 

This form of vulvo-vaginitis not being purulent as it would be 
if the eruption were eczematous, or herpetic, or if the inflamma- 
tion were more diffuse and deep-seated, the 

The leucorrhoea. r» -i i i-itt - • 

amount of the leucorrhceal discharge is not m 
proportion with the local suffering. Mrs. T. has but little flow of 
this kind. Where, however, the eruption and the inflammation 
extend within the cervix uteri, and possibly into the uterine cav- 



ON THE DISEASES OF WOMEN. 589 

ity, as there is good reason for believing that they sometimes do, 
the quantity of mucus and of pus secreted may be very large. 
In middle-aged and more vigorous subjects the presence of these 
little papulae (as in case of other vegetative growths within the 
vulva), may excite a very troublesome leucorrhoea. If the dis- 
charge that is poured out is thin and serous in character, it is very 
apt to dry upon the parts and then to crack and break into little 
scales which cause an intolerable pruritus. Some of these patients 
will tell you that they have no leucorrhoea, when in fact they are 
deceived and the discharge is disposed of in this way. In rare 
instances the eruption invades * the urethra and occasions a very 
persistent and troublesome form of urethritis. 

The entire exemption of our patient from urinary troubles, such 

as strangury and the like, affords an indirect proof that she has 

not suffered from any variety of uterine devia- 

A practical inference con- . „ n 

ceming uterine displace- tion. Jb or this reason I ielt almost confident 

ments * it i • • 

that her womb was in situ before passing the 

sound. You remember that the attachments between the neck 
of the uterus and the bladder are such that it is next to impossi- 
ble to displace the former without pressing upon, or changing the 
position of, the latter. And when a woman tells you that she is 
not subject to, and has not suffered from, vesical troubles of any 
kind, you may be reasonably assured that her womb is where it 
should be. But you are not to conclude that because she has 
strangury, dysuria, etc., therefore her womb is displaced; for 
these symptoms may arise from other and very different causes. 

The prognosis is generally favorable, but the time required for 

the cure will vary according to circumstances. Such cases recover 

more readily in winter than in summer, in cool 

Prognosis. , . m 

than in warm climates, and in young than in 
old patients. Scrofulous persons, and those who are predisposed 
to aphthous conditions, or to chronic cutaneous eruptions of what- 
ever kind, get well very slowly. The syphilitic taint ma} r retard 
the cure. If it follows the climacteric very closely, or co-exists, 
as in the case before us, with rheumatism, we shall not be war- 
ranted in promising very speedy and permanent relief. 

Treatment. — As affording direct relief, and being capable of 
making life tolerable, the topical treatment is very important. 
The proper palliatives have already been mentioned when speak- 



Constitutional treatment. 



,390 LECTURES, CLESTCAL AND DIDACTIC, 

ing of pruritus of the vulva.* Cleanliness, frequent bathing with 
cool or tepid water, and the application of a 

Topical treatment. n 1 . 

bland demulcent, as bran-water, glycerine, 
almond oil with or without chloroform, or of the muriate of 
hydrastin with glycerine, will answer an excellent purpose. 
Cloths or compresses anointed or saturated with one of these 
may be applied to the vulva : or the cotton tampon may be the 
vehicle for introducing the same into the vagina. 

The diet should be plain and unstimulating, the exercise mod- 
erate, and coitus positively forbidden. 

The internal remedies should be suited more especially to the 
character of the eruption, the patient's peculiar dyscrasia. and 
the relation of the disease to child-bearing and 
the climacteric. Among the remedies that may 
be required in different cases are rhus tox., sepia, sulphur, arseni- 
cum, calcarea carb., conium, hydrastis, croton tig., carbo veg., 
mercurius. natrum mur., kali carb.. creasotum, thuja and the 
mineral acids. 

Taking the peculiar eruption, and the incidental rheumatic 
symptoms as a guide, I shall select the rhus tox. as the remedy 
for this patient. She will take of the 3d attenuation a dose every 
three hours. This frequent repetition is justified in her case by 
the severity of her rheumatism. She will also have the glycerine 
and hydrastin applied locally morning and evening. 



IXEANTTILE LEECOEEHCEA. 

There is a form of vulvo -vaginitis to which little girls are liable, 
and of which I may speak in this connection. The mucous mem- 
brane reflected over the vulva becomes so in- 
flamed, heated and irritated, that the child has 
no rest, but is constantly tempted to relieve itself by rubbing the 
parts, which only increases the trouble and extends the mnamma- 
tion. Sometimes the first symptom complained of is pain on 
passing water, which also creates a sense of scalding and itching. 
This is accompanied by dryness, redness, and heat of the inflamed 
surfaces. Soon, however, the parts become moist from the exu- 

* See page 159. 



ON THE DISEASES OF WOMEN. 591 

dation of a thin, colorless mucus which, as the case progresses, 
becomes of a thick and creamy consistence. 

The amount and quality of the leucorrhceal discharge varies 

with the constitutional taint, as well as with the duration of the 

disease. In scrofulous children, more espe- 

The leucorrhceal flow. .„ ... _ - 

cially it they have been allowed improper lood 
and have not been kept in a cleanly, healthful condition, the leu- 
corrhceal flow may be either very copious, or perhaps ichorous and 
corrosive. In bad cases of this kind there is not only inflamma- 
tion, but ulceration also of the vaginal mucous membrane. When 
these patches of ulceration are present, they may be seen by 
stretching the labia apart. More rarely they are found in the 
upper portion of the vagina. 

The causes of this form of vaginitis in children are numerous. 
Sometimes the urine has such acrid properties as by its flow over 

the vaginal surface to induce this disease. 

Simple catarrhal urethritis may develop into 
vulvo- vaginitis. Or it may arise idiopathically from exposure to 
cold, or a sudden check of perspiration. Sometimes it takes 
the form of an epidemic, and prevails in winter along with a more 
or less severe influenza. I have known it to alternate with a 
severe and troublesome coryza. It may attack several children in 
the same family or neighborhood. Irritation of the rectum, and 
sometimes of the colon, may induce it. In some instances it is 
due to the presence of worms that have escaped at the anus, and 
crawled within the vaginal orifice, where, by their presence, they 
excite a great degree of itching and irritation. And sometimes 
there is no doubt that it has been caused by a mischievous rub- 
bing and irritation of the parts by nurses and servants who have 
had the children in charge. 

The proper treatment for cases of infantile leucorrhcea is first, 
if possible, to remove the cause. It is very important to avoid 

exposure to cold and wet, and to order a proper 

and digestible diet. Cleanliness, bathing and 
drying the parts carefully afterwards, either Avith a very soft 
towel, or better still, with an application of finely pulverized 
starch, or lycopodium powder, as in case of infants to prevent 
intertrigo, are very useful. 

If the complaint is related to influenza, the internal remedies 



592 LECTURES, CLINICAL AXD DIDACTIC, 

will be the same as are suited to the epidemic catarrhal inflamma- 
tion, no matter where it is located. If it occurs in scrofulous 
children, the remedies which suggest them- 

Local and general. 

selves, and which are most useiul, are calcarea 
carb., hepar sulph., and mercurius. A majority of cases may be 
cured with pulsatilla, or calcarea carb. 

If the passage of the urine occasions great suffering, give can- 
tharis, and have cloths that have been dipped in warm water 
applied over the vulva. If there is ulceration, or aphthous in- 
flammation, add hydrastin or calendula to the water. If ascarides 
have created the mischief, order lard to be smeared about the 
anus, or a decoction of garlic, or an injection of olive oil to be 
thrown into the bowel, and give the child teucrium. 

It is important that children who have this affection should not 

be allowed to sleep in the same bed, or to be washed with the 

same towels as those who are healthy. For 

Isolation. . .. „ 

although the disease is not always easy 01 com- 
munication, }'et it might happen that it would spread through a 
whole family of little ones, and occasion much suffering and anxi- 
ety. It is a pleasure to be able to assure the mother or nurse 
that, with proper time and care, this disease may be readily and 
3ertainly cured. 



I NDEX 



A. 



Abortive dyscrasia, in membranous dys- 

menorrhoea, 194. 
Abortion, a contingent of retroversion, 27. 

prognosis in retroversion, 27. 

with misplaced pains, 52. 

from over exertion, 53. 

habit of, 54. 

intermittent, 54. 

danger from ovaritis after, 131. 

argument upon, 337. 

as a cause of disease, 338, 339, 

sequelae of, case, 334, 339, 340. 

causes of, 335. 

and fibroids, 548. 

ill effects of wrong diagnosis, 340. 

sequela;, difficulty of recognizing, 
340. 

third month, differential diagnosis, 

341- 

treatment of, 341, 343. 

a cause of uterine irritability, 483. 

relative immunity from, in fibroids, 

543-* 
remote consequences of, 563. 
followed by metrorrhagia, 565. 
Abortionist, sophistries of the, 336. 
Abrasion, causes of uterine, 152. 

simple, in sore nipples, 174. 
Abdominal cramps and pains in preg- 
nancy, 61. 

cramps, characteristic symptoms of, 
63. 
Abdominal tympanites, and delirium, 299. 
Abdominal tumor, location and growth, 

367. 
Abscess of mammary gland, with sinus, 

49. 

mammary, from sore nipples, 173. 

pelvic, etc., 438, 439. 

pelvic, a sequel of pelvic celluli- 
tis, 450. 
Aconite, in abortion, 342. 

in pelvic cellulitis, 457. 
Acids — nitric, sulphuric and muriatic, in 

stomatitis, 219. 
Acute cervical metritis — varieties of, 275. 

— prognosis and treatment of, 277. 

38 



Adherent placenta a cause of haemorrhage, 

Albuminuria, in pregnancy, 554. 

in puerperal convulsions, 233, 244, 
247. 
Alcoholic stimulation in hysteria, 309, 310. 
Alimentary disorders, serious nature of, 

479- 

Alimentary symptoms in climacteric, 502. 
Alternation of remedies, 87. 
Amaurosis, in puerperal convulsions, 244. 
Amenorrhcea, 56, 560. 

treatment of, 107, 109, 377, 477. 

with hysterical spasms, 56. 

resembling chorea, 56. 

and chlorosis, 93. 

hereditary in chlorosis, 96. 

preceded by chlorosis, 100. 

with supra-orbital neuralgia, 106. 

definition and varieties, 374. 

symptoms, 375. 

complicated with phthisis, 376. 

" forcing medicines " injurious, 376. 

diagnosis of, 376. 

prognosis of, 377. 

anticipative treatment, 377. 

with prolapsus uteri and vomiting, 
474, 475- 

prolapsus the exciting cause, 476. 

with vomiting, 474. 

remedies, 477. 

cardinal symptoms, 477. 

etc, with spinal irritation, 580. 

and spinal irritation, 521. 

and dysmenorrhcea, with pruritus, 

. I57 - 
Ammonia and alcohol, in hysteria, 313. 

Ammonium muriaticum, in ovarialgia, 

169. 
Ammonium carb., in stomatitis, 221. 
Analysis of ovarian irritation, 557. 
Anaemic murmur, in chlorosis, 95. 
Anaemia, in stomatitis materna, 215, 

216. 
Anaesthetics in puerperal convulsions, 

251. 

Antigalactics, 34. 

Antagonism of the diaphragm and perin- 
eum, 90. 



594 



INDEX. 



Anti-spasmodics in hysteria, objections to, 

3 °9- . 
Aphonia from laryngitis, and hysteria, 

290, 291. 
Apis mel., in second stage of pelvic cellu- 
litis, 459. 
Appetite in chlorosis, 95. 
Apoplectic aphonia in hysteria, diagnosis, 
291. 

form of puerperal convulsions, 225, 
238, 243, 261. 
Aphthous ulceration, and sore nipples, 

ulceration of os and cervix uteri, 

43i, 435- 
Arnica, in abortion, 342. 

and aconite, in ovarialgia, 167. 
in pelvic cellulitis, 457. 
and Aconite in ovaritis, 142. 
Arsenicum album, in stomatitis, 220. 
Ascites, diagnosis of, from ovarian dropsy, 

365, 366. 
Astringents in menorrhagia, 70. 

uterine, physiological argument 
against, 72. 
Atresia of the vagina, 391. 

-cervical, causing dysmenorrhcea, 

394- 
Atropine in ovarialgia, 168. 
Atrophy and induration, ovarian, 140. 

absence of, in hysterical hemiplegia, 

527- 



13. 



Bad breath, in chlorosis, 95. 

" Back-ache," 510. 

Barrenness, caused by leucorrhcea, 23. 

from gonorrhceal ovaritis, 135, 14c*. 
Baryta carbonica, in stomatitis, 221. 
Baths, etc., in ovaritis, 142. 
Bath, warm, in ovarialgia, 167. 

warm or cold, in hysteria, 313, 314. 
Belladonna, in ovaritis, 137. 

in abortion, 342. 

in pelvic cellulitis, 457. 

in interstitial fibroids, 552. 
Bilious colic during pregnancy, 143-147. 

complication in cervicitis, 571. 

derangement self-limited in preg- 
nancy, 146. 
Biliary disorders predisposing to uterine 

catarrh, 347. 
Bi-manual examination, 549. 
Binder, value of, in haemorrhage, 83. 
Bladder distended, distinguished from 

ovarian dropsy, 372. 
Bladder — emptying of — in uterine haem- 
orrhage, 82. 
Blood changes in chlorosis, 98. 
Brain symptoms in puerperal convulsions, 
229. 



J Brandy, wine and whiskey, in hysteria, 
1 3io,'3i3. 

Bladder and urethra, disease of, 329. 
j Breasts, changes in the, 327. 

support for, in galactorrhcea, 36. 
I Breath, bad, in chlorosis, 95. 
I Bright's disease, in puerperal convulsions, 

236, 240, 246. 
I Bryonia alba, in ovaritis, 139. 
1 Buccal symptoms in stomatitis materna, 
213. 
Burning pain in ovaritis, 21. 
Burrowing abscess of mammary gland, 49. 



Cachexia chlorotic, remedies for, 103. 
Calcarea carbonica, in stomatitis, 221. 
Calendula, in endo-cervicitis, 357. 

in ovaritis, 141. 
Camphor, in puerperal convulsions, 257. 

coffee, chloroform, etc., in hysteria, 

3I3 : 
Cancer, cervical, compared with metritis, 

571- 
Carcinoma — use of the sound, 493. 
Cardiac affections in chlorosis, 102. 

symptoms in chlorosis, 94. 
Cardinal symptoms, 477. 
Catamenial haemorrhages, in climacteric, 

506. 
Catarrh, uterine and vaginal, from ovaritis, 

22. 
Causes of abortion, 335. 
Cause of delivery in molar pregnancy, 40. 
Caustics, use of, in uterine ulceration, 153. 
Cataleptic convulsions, 236. 
Cauterization, indiscriminate, of os uteri, 
24, 208, 358, 433. 

causing dysmenorrhcea, 395. 
Cellulitis, pelvic, conditions promoting 
resolution, 443. 

epidemic tendency of, 451. 

diet, 460. 

stimulants, 460. 

emollients, 461. 

remedies to promote suppuration, 
461. 

opening the abscess, 461. 

after-treatment, 455-462. 

etc., 438, 439. 

case, 452-3-4. 

nature of, 445. 

distinguished from fibroids, 543. 

a contingent of uterine surgery, 446. 
Cellulitis peri-uterine and synonyms, 439. 

location of the tumor, 442. 

formation of the tumor, 441. 

sequelae, 450. 
Cephalalgia connected with ovulation, 265. 
Cerebral symptoms in chlorosis, 94. 

with puerperal convulsions, 246. 



INDEX. 



595 



Cervical leucorrhcea, not uterine catarrh, 
346. 

atresia causing dysmenorrhcea, 394. 
Cervicitis, a new diagnostic test, 572. 

chronic corporeal, 569. 

contact, 570. 
Cervical endo-metritis, 344. 

differential diagnosis, 277. 

symptoms, 348. 
Cervical metritis, postural treatment, 277. 

rare in nulliparae, 275. 

acute, causes of, 276. 

acute, prognosis and treatment, 277. 

local measures, 279. 

compared with cancer, 571. 

treatment, 572, 277. 

prognosis, 572. 
Cervical leucorrhcea, burning sensations, 
350 ; 

secretions and discharges, 360. 

speedy cure, 354. 

causes, 350. 
Cervical mucous membrane, extent of 

the, 345. 
Cervix, changes in the — in tumors of 
uterus, 532. 

incision of, for menstrual retention, 

39 1 - 

diseases of, use of the sound in, 491. 

the condition of the, 550. 

in pregnancy, changes in the, 328. 

incision of the, 537. 

-uteri inflammation, 588. 
Cessation of the menses, case, 499. 
Change of climate in menorrhcea, 425. 

in stomatitis, 219. 
Change of life, case, 4gg. 

influence of fibroids, 550. 
Chapped nipples, 174. 
Chalybeate waters in chlorosis, 106. 
Chlorosis, 93. 

and amenorrhcea, 93. 

digestive symptoms in, 93. 

cardiac symptoms in, 94. 

cerebral symptoms in, 94. 

the anaemic murmur in, 95. 

the pulse in, 95. 

incidental symptoms, 95. 

the appetite in, 95. 

menstrual irregularities in, 96. 

hereditary amenorrhcea in, 96. 

and dysmenorrhcea, 97. 

in pregnancy, 97. 

discoloration of the skin in, 97. 

the mental state in, 97. 

and scrofulosis, 98. 

haematogenesis in, 98. 

blood changes in, 98. 

spanaemia in, 99. 

the nervous theory of, 99. 

preceding amenorrhcea, 100. 

danger from incidental disease, 102. 



Chlorosis, menstrual complications of, 100. 

and jaundice compared, 101-2. 

treatment for emotional cause, 103. 

remedies for general states, 103. 

iron in, 104. 

citrate of iron and strychnia in, 104. 

arsenic and strychnia in, 104. 

wrong to force the menses in, 104. 

spasmodic dysmenorrhcea in, 105. 

adjuvants in, 105. 

diet in, 105. 

exercise and travel in, 105. 

mineral waters in, 106. 

cheerful society in, 106. 

marriage in, 106. 

sea-bathing in, 106. 
Chlorotic cachexia, remedies for, 103. 
Chlorotic symptoms in ovarian irritation, 

565. 
Chloro-anaemia in menorrhcea, 424. 
Chloroform in ovarialgia, 167. 

in puerperal convulsions, 251, 253. 
Cholestraemia, pregnancy and uterine dis- 
ease, 145. 
Chorea-like spasms in amenorrhcea, 56. 
Chronic cervical metritis, 569. 

corporeal cervicitis, 569. 

ovaritis with leucorrhcea, 20. 
Cimicifuga in ovarialgia, 170. 
Circulation at the climacteric, remedies for 

disorders of, 508. 
Circulation, disorders of, in climacteric, 

503- 
Citrate of iron and strychnia in chlorosis, 

104, 106. 
Claiming too much, 585. 
Climacteric, diseases of puberty returning, 
501. 

crisis in the life of women, 499. 

duration of menstrual life, 500. 

old diseases cured by, 501. 

with ovarian irritation, 557. 

cause of the danger, 506. 

period predisposing to uterine de- 
viations, 18. 

change of life, 499. 

causing vulvo-vaginitis, 589. 

new disorders induced, 501. 

importance of the change, 500. 

symptoms, 501, 505. 

varying age, 499. 

haemorrhage at, 568. 

predisposition incident to, 500. 

treatment, 506. 

prognosis, 505. 

and spinal irritation, 521. 

simulating pregnancy, 502. 

disorders of circulation, 503. 

nervous symptoms, 503. 

disorders of special senses, 504. 

disorder of respiratory system, 504. 

rheumatism in, 505. 



596 



INDEX. 






Climacteric, neuralgia in, 505. 

Clinical deductions in metrorrhagia, 566. 

inferences, their weight, 478. 
Coitus interdicted during ulceration of w., 

208. 
Coccyodynia with spinal irritation, 519. 

diagnosis from uterine irritability, 
486. 
Coffea in hysteria, 89. 
Coffee causing irritable uterus, 482. 
Cold and dampness in ovaritis, protect 

from, 142. 
Colic, bilious, treatment during pregnan- 
cy, 143-147. 
uterine, 64, 201. 
Colocynth in ovaritis, 137. 

in ovarialgia, 169. 
Complications in suppressed menstruation, 

381. 
Complicated diseases of women, 584. 
Compress in uterine haemorrhage, 83. 
Conception, false, 37. 

morbid anatomy of, 37. 
" Congestive " headache, diagnosis from 
menstrual, 267. 
with puerperal convulsions, 246. 
stage in peri-uterine cellulitis, 440. 
Constipation, 587. 

at climacteric causing prolapsus, 18. 
from rectal paralysis, 271, 273. 
in chlorosis, 95. 
Constitutional disease, stomatitis materna, 

213. 
Contentment in hysteria, 312. 
Convulsibility in pregnancy, signs of, 555. 

increased by uraemia, 235. 
Convulsions, 560. 

or spasms ? 88. 

etc., with spinal irritation, 581-2. 
Convulsions puerperal, prior to seventh 
month, 226. 
influence of delivery on arrest of, 226 
coming on of the fit, 227. 
clinical history, 226. 
frequent in birth of male children, 

227. 
frequent in head presentations, 227. 
liability of recurrence, 227. 
with Bright's disease. 236, 241, 246. 
noting progress of labor, 249. 
premonitory symptoms, 228, 229. 
mechanical and nervous origin, 232. 
favorable symptoms, case, 239. 
the patient's posture, 247. 
serious complications, 240. 
albuminuria, 234, 244, 247. 
the toxaemic theory, 233. 
giving the remedies, 261. 
Convulsions, prae- and post-partum com- 
pared, 241. 
during parturition cause of child's 
death, 242. 



Corrosive leucorrhceal flow, 591. 

Cough a cause of uterine displacements, 
91. 
hysterical, 289. 

Cramps and pains, abdominal, in preg- 
nancy, 61. 

Cramps after the fourth month, 61. 

Cramping pains, in prolapsus uteri, 272. 

Critical age, case, 499. 

Cupping, dry, in puerperal convulsions, 

257- 

Cutaneous neuralgia, diagnosis from spu- 
rious peritonitis, 63. 

Cystitis, diagnosis from urethritis, 180. 



D. 



Death of embryo in molar pregnancy, 38. 
Decidua menstrualis, the inflammation in, 

is accidental, 190. 
Decidua menstrual, shape and size of 

membrane, 191. 
Deductions, clinical, in metrorrhagia, 566. 
Delirium, hysterical, 294. 
Delivery, cause of, in molar pregnancy, 40. 
Depressing the uterus, 549. 
Diagnosis of spurious peritonitis from 
cutaneous neuralgia of the ab- 
domen, 63. 
incorrect in prolapsus uteri, 85. 
wrong, ill effects of, 340. 
in ovaritis, 130. 

of pregnancy from dropsy, 369. 
Diagnostic rule in menorrhcea, 420. 
Diaphragm and perineum, antagonism of 

Diarrhoea in chlorosis, 95. 

with nursing sore-mouth, 212, 215. 
Diathesis, hysterical, 316. 

remedies for, 316. 

neuralgic, in ovarialgia, 161. 
Diet in bilious colic, 147. 

in chlorosis, 105, 106. 

and exercise in endo-metritis, 355. 

in galactorhoea, 36. 

and drinks in urethritis, 181. 

in leucorrhcea, 45. 

in mammary abscess, 52. 

in ovarialgia, 166. 
Difference between menstrual suppression 

and retention, 57. 
Digestive complications with endo-cervi- 
citis, remedies, 361. 

derangement, with sore mouth, 214. 

derangement in ovarian irritation, 
565. 

disorders from vaginal and uterine 
injections, 72. 

disorders and uterine luxations, 
149. 

disorders, with pruritus, 159. 



INDEX. 



597 



Digestive disorders in climacteric, reme- 
dies, 507. 
symptoms in chlorosis, 93. 
Dilatation for intra-mural tumor, 550, 554. 
for sub-mucous fibroids, 538. 
failure of, 583. 
dangers of, 583. 
in dysmenorrhcea, 400-405. 
Diphtheria causing vaginitis, 588. 
Diphtheritic ulceration of the os uteri, 436. 
Direct and reflex symptoms, 570. 
Discharge in ovaritis, drain from, exces- 
sive, 133. 
Disease versus symptoms in prolapsus 

uteri, 151. 
Diseases caused by abortion, 338, 339. 
of bladder and urethra, 329. 
of women are complicated, 584. 
Displacements, uterine, inference, 589. 
Distinction practical in uterine haemor- 
rhage, 564. 
Diversion at the climacteric, 506. 
Dropsy at the climacteric a cause of pro- 
lapsus, 18. 
in chlorosis, 96, 102. 
as a sequel of ovaritis, 126. 
ovarian, differential diagnosis of, 

363- 
ovarian, distinguished from fibroids, 

542. 
of the face, etc., in pregnancy, 555. 
of the heart, diagnosis from hyste- 
ria, 288. 
ovarian, from physometra, diagno- 
sis, 372. 
and pregnancy co-existing, 369. 
a precursory symptom of puerperal 
convulsions, 228. 
Drugs aggravating hysterical delirium, 

295. 

Dyscrasia abortive in membranous dys- 
menorrhcea, 194. 
Dystocia resulting in puerperal cellulitis, 

446. 
Dysmenorrhoea and amenorrhcea, with 
pruritus, 157. 
and chlorosis, 97. 
causing ovaritis, 111-119. 
spasmodic in chlorosis, 105. 
symptoms, 395, 396, 397. 
use of sepia, 585. 

etc., diagnosis from uterine irrita- 
bility, 487. 
relation of the flow to the degree 

of pain, 409. 
indications for remedies, 409. 
warm water, not cold, 410. 
diagnosis, physical exploration, 398. 
passing the sound in, 398. 
the flow and what it signifies, 398. 
prognosis of, 398. 
surgical treatment, etc., 399. 



Dysmenorrhcea and amenorrhcea, intro- 
duction of instruments in, 400. 
dilatation, 400-405, 410. 
hints on use of various tents, 401. 
precautions in practicing dilata- 
tion, 402, 405. 
incision of the cervix uteri, 402, 

403- 
neuralgic, causes, 405, 407, 409. 
and fibroids, 548. 
obstructive, 392. 
obstructive, causes, 394. 
Dymenorrhcea, membranous, 182, 
rare, 188. 

consequent uterine affections, 193. 
rheumatic complications, 194. 
in case of repelled eruption, 195. 
reflex symptoms irrelevant, 195. 
ovarian symptoms significant in, 

195- 
local applications in, 196. 
marriage, conception, etc., 196. 
the sponge tent in, 196. 
Dysmenorrhceal haemorrhage, 567. 



Eclampsia puerperal, reflex causes, 233. 

pulmonary disease a sequel, 243. 

with Bright's disease, 236, 241, 246. 
Effects, possible, of hysteria, 282. 
Electricity and magnetism in menstrual 

headache, 270. 
Electricity in hysteria, 313, 314. 
Emaciation in chlorosis, 96. 
Embryo, death of, in molar pregnancy, 38. 

retention of, in molar pregnancy, 

39- 
Emmenagogues, 385. 

at puberty, 562. 
Enigmatical nature of hysteria, 284. 
Emotional causes of hysteria, 282. 
Empiricism a dark-lantern, 514. 
Endo-cervicitis, 344. 

peculiarities of the discharge, 359. 

origin of the flow, 353. 

diagnosis from cervical metritis, 

353- 
prognosis, 353. 

remedies for, 357, 358, 361, 362. 
weakness of eyes in, 351. 
examination with speculum, 352. 
diagnosis, 352. 
incidental ulceration, 352. 
the causes of, 354. 
diet, travel and exercise in, 355. 
vaginal injections in, 356. 
use of glycerine in, 356, 357. 
use of pessaries in, 357. 
practical hints for treatment, 361. 
Endo-metritis, or endo-cervicitis, 344. 
symptoms, 34S. 



598 



INDEX. 



Enlargements of liver and spleen, physi- 
cal exploration, 373. 
Enucleation for interstitial fibroids, 553. 
Epidemic tendency of peri-uterine cellu- 
litis, 451. 
Epidemic ovaritis, 112. 
Epilepsy in chlorosis, 102. 

in climacteric, 503. 

in eruptions, 108. 

diagnosis of, from hysteria, 300. 
Epileptiform variety of puerperal convul- 
sions, 225, 226, 238, 261, 
Epilepsia renalis, 238. 
Eruptions and hysteria, 108. 

and insanity, 108. 

and epilepsy, 108. 

and neuralgia, 108. 

and paralysis, 108. 
Eruption, prurigenous, 587. 

purulent in vulvo vaginitis, 588. 

repelled in dysmenorrhea, mem- 
branous, 195. 
Erysipelas, allied to pelvic cellulitis, 445. 
Escharotics, causing uterine irritability, 

483. . 

indiscriminate use of, 483. 
Ether, sulphuric in puerperal convulsions, 

2 5 T - 
Etiology of ovarian neuralgia, 161. 

Exaggeration, hysterical, 285. 

Examination, the bi-manual, 549. 

Excessive abdominal development in 

pregnancy, 66. 

Excision of the tumor, 537. 

Excoriated nipples, 170—176. 

Excision of vascular tumor, 577. 

Exemption from ovarian disease, 64. 

Exercise proper in hysteria, 310. 

in menorrhcea, 425. 

and travel in chlorosis, 105. 

mental and physical, in bilious 
colic, 147. 
Expedients available in uterine haemor- 
rhage, 80. 
Extirpation of the ovaries, 545. 

of the uterus, 546. 
Eyes, weakness of, in endo-cervicitis, 351. 



False conception, 37. 

Faradization in spinal irritation, 524. 

Fashionable pretexts for weaning infants, 

32. 
Faecal accumulations in ovarialgia, 168. 
Faeces, impaction of, distinguished from 

fibroids, 543. 
" Festina lente " in introducing the sound, 

499. 
Fevers eruptive, causing vaginitis, 588. 
Fibro-cysts and ovarian-cysts compared. 

372. 



Fibro-cystic tumor of the uterus, 426. 

-cystic growths, ovarian dropsy, 
ascites, or pregnancy, 371. 
Fibroids, curable in their incipiency, 551. 
and tumors, relative rapidity of 

growth, 371. 
sub-peritoneal, size of, 540. 
sub-peritoneal, number of, 540. 
Fibroid tumors of the uterus, diagnosis, 
533- 

homologous growths, 530. 
causes, 533. 
prognosis, 535. 
symptoms, 531. 
frequency, 529. 
pathological anatomy, 529. 
risks of an operation, 536. 
treatment, 536. 
varieties, 530. 
Fibroids, uterine, dangers in dilatation, 
554- 
from dropsy, diagnosis, 369. 
interstitial, 547. 
symptoms, 547. 
interstitial, diagnosis, 549. 
interstitial, prognosis, 550. 
relative curability of the various, 

550. 
sub-mucous, Dr. Atlee's operation, 

537- 
sub-mucous, intra uterine, 530. 
sub-mucous, radical cure, 538. 
sub-peritoneal, frequency, 540. 
sub-peritoneal, effects of pressure 
on, 541. 
Fibroid tumors of the uterus, 547. 
Fibroids-uterine, diagnosis from cellulitis, 
449. 

various forms of degeneration, 551. 
Flow — menstrual, forcing it to return, 59. 
Foetal heart-sound, 327. 

an unequivocal sign of pregnancy, 
368. 
Follicle, natural and morbid, in ovaritis, 

125. 
Follicular stomatitis, 213. 

vaginitis, diagnosis from vulvo- 
vaginitis, 588. 
Forcing medicines (emmenagogues), 376. 
the menstrual flow to return, 59. 



Galactorrhcea, 31. 

— prophylactic treatment of, 34. 
Gastralgia in chlorosis, 96. 
Gastric disease, uterine, treatment of, 478. 

disorder, with nursing sore mouth, 
214. 

symptoms in early pregnancy, 26. 

symptoms in ovarian irritation, 565. 



INDEX. 



599 



Gastrotomy in sub-peritoneal fibroids, 

545- 
Gastro-enteritis in chlorosis, 96. 
-hysterical disorders, 292. 
-intestinal disorders incident to 
pregnancy, 64. 
Gelseminum in ovaritis, 138. 

for dysmenorrhcea, 410. 
Generative organs and heart, sympathy 
between, 94. 

organs, medicines required, 416. 
system at climacteric remedies for 

disorders of, 508. 
system, disorders of the, in climac- 
teric, 504. 
Gestation, accompanied by sore mouth, 
211, 2l6. 

hysteria during, 282. 
Glandular lesions, 345. 
Glycerine in endo-cervicitis, 357. 

in ovarialgia, 167. 
Gonorrhoea, diagnosis from urethritis, 180, 

182. 
Gonorrhceal ovaritis, 121. 

ovaritis, barrenness from, 135, 141. 
Granular vaginitis, diagnosis from vulvo- 
vaginitis, 588. 
Green sickness, 97. 



H. 



Habit of aborting, 54. 

Hamamelis virg., in ovarialgia, 167. 

in ovaritis, 138, 141. 
Harmful medication in pseudo-prolapse, 

86. 
Haemorrhagic diathesis, 77. 

in climacteric, 502, 568. 
Haemorrhage in climacteric, remedies for, 
507- . 

in fibroid tumors of the uterus, 

531. 

Haemorrhages in chlorosis, 102. 
Haemorrhage into the ovary in ovaritis, 
126. 
post-menstrual, 567. 
remedies for, 566. 
specially incident to rapid labors, 

76. 
persisting, without injury, 422. 
in ovarian dropsy, 369. 
uterine, caused by adherent pla- 
centa, 76. 
uterine, available expedients in, 80. 
uterine, nitric acid, 565. 
in uterine fibroids, 369. 
from uterine inertia, 77. 
after twin delivery, 75. 
Haemorrhagic diathesis in menorrhcea, 

424. 
Haemostatics, sponge-tent, 537. 



Haematemesis, vicarious with spinal irri- 
tation, 581. 
Haematogenesis, 42, 98. 
Hasmatocele — pelvic, diagnosis from pel- 
vic cellulitis, 449. 
Hair, dressing of, forbidden in prolapsus 

uteri, 153, 163. 
Headache, congestive with puerperal con- 
vulsions, 246. 
from uterine displacements and 

leucorrhcea, 264. 
from causes which simulate ovula- 
tion, 265. 
Headache, menstrual, diagnosis from 
" sick" headache, 266. 
peculiar symptoms, 263. 
internal remedies, 270. 
Heart, dropsy of, in hysteria, 288. 
alleged displacement of, 289. 
sound, foetal, 327. 
an unequivocal sign of pregnancy, 

363. 
and generative organs, sympathy 

between, 94. 
valvular disease of, 287. 
Hectic fever with' pelvic cellulitis, 444. 
Hereditary predispositions in climacteric, 

_ 506. 
Hernia from ovarialgia, 165. 
Hydatids, uterine causing tumors, 534. 
Hygienic precautions in prolapsus uteri, 

19. 
Hygienic rules, in climacteric, 506. 
Hygienic treatment in hysteria, 316. 
Hydrastis, etc., in endo-cervicitis, 357. 
Hyperaesthesia, a species of, 481. 
Hyperplasia-cervical, symptoms, 570. 
Hypochondria diagnosis from hysteria, 

296. 
Hypochondria with hysterical delirium 

295, 296. 
Hysteria, its real nature, 304. 
prognosis, 304. 

alcoholic stimulation in, 309, 310. 
congenital predisposition to, 304. 
Hysteria incident to menstrual life 88. 
possible effects of, 282. 
contentment a cure for, 312. 
in menstrual life, 564. 
the pulse in, 89 
narcotics and anti-spasmodics in, 

309. 
emotional causes of, 282. 
domestic infelicities in, 312. 
spurious symptoms in, 2S4. 
the doctor's personal address in its 

cure, 307. 
value of tact in curing, S9. 
in a woman aged sixty, S7. 
value of impromptu resources in, S9 
with nymphomania, vaginismus, 
etc., 303. 



600 



INDEX. 



Hysteria, may counterfeit labor, 299. 

a pathological kaleidoscope, 315. 
diagnosis from pectoral disease, 

289. 
the doctor's habits, etc., 307. 
a species of malingering in, 285. 
occasioned by uterine colic, 203. 
complications and peculiarities of, 

290. 
the patient's manner in, 88. 
secondary effects of, 286. 
the real problem in, 307. 
incongruous symptoms in, 285. 
at the climacteric, 107. 
the pupil in, 88. 
and eruptions, 10S, 109. 
or spinal irritation ? 302. 
and skin disease, 108. 
treatment of, general remarks upon, 

305- 

mental remedies in, 312, 

remedy for incompatibility, etc., 
308. 

and rheumatism with oyarian irri- 
tation, 557. 

diagnosis of, 286. 

coincident menstrual disorders in, 
316. 

during gestation, 282. 

among the " better" classes, 3 it. 

domestic occupation as a remedy, 

.311- 

diagnosis from asthma, 290. 
diagnosis from dropsy of heart, 288. 
diagnosis from hypochondria, 296. 
diagnosis from disease of heart, 287. 
leading characteristics and effects, 

286. 
suspicious symptoms in, 284. 
yyith gastric affections, 292. 
precaution, tact, 314. 
good nature, taciturnity, 315. 
treatment in the interyal of the 

paroxysms, 315. 
caution in exclusion of symptoms, 

315. 

incompatibility between physician 

and patient, 308. 
and epilepsy, diagnosis, 300. 
legitimate symptoms, 317. 
not a botia fide disease, 304. 
coincident lesions of uterus, ova- 

ries, etc., 317. 
proper exercise in, 310. 
the smallest items not always triyial 

in, 308. 
and the menstrual molimen, 281. 
from insanity, diagnosis of, 292. 
various complications of, 317, 318. 
tact versus talent in its treatment, 

312. 
treatment during the fit, 313. 



Hysteric condition aggravated by modes 

of living,304. 
Hysterical aphonia, 290, 291. 
aphonia prognosis, 291. 
affections of the joints, 303. 

" " diagnosis of, 303, 

convulsions puerperal, chloroform, 

251,-254. 

delirium, 294. 

delirium with hypochondria, 295. 

delirium, diagnosis from peritoni- 
tis, 297. 

delirium, aggravated by drugs, 295. 

delirium incident to fevers, 295. 

delirium in child bed fever, 295. 

diathesis, remedies, 316. 

mimicry, 525. 

headache, diagnosis from menstrual 
267. 

spasms in amenorrhoea, 56. 
Hysterical complications in prolapsus uteri, 
150. 

form of puerperal convulsions, 225, 
226, 238, 260. 
Hysterical cough, 289. 

exaggeration, 285. 

diathesis in ovarialgia, 162, 165. 
Hysterical hemiplegia, case, 524. 

diagnosis, 526. 

differential signs, 527. 

occurring in males, 527. 

prognosis, 528. 

adjuvants, treatment, 328. 

remedies, 528. 
Hysterical form of peritonitis, 297. 

and nervous symptoms and reme- 
dies, 362. 

side-ache resembling pleurisy, 298. 
Hysteralgia, ca?e, 4S0. 



Ignatia in ovarialgia, 169. 

Impaired lacteal secretion from leucor- 

rhoea, 41. 
Importance of special pathology, 23. 
Incision of the cervix, 537. 

and of the hymen for menstrual sup- 
pression, 391. 
in spinal irritation, 5 S3. 
Incongruous symptoms in hysteria, 285. 
Indigestion causing dysmenorrhoea, 396. 

in uterine ulceration, 322. 
Indiscriminate cauterization of os uteri, 24, 

358, 394, 433, 483- 
Induction of premature labor, 70. 
Induration and atrophy, ovarian, 140. 
Infantile leucorrhcea, symptoms, 590. 

remedies, 592. 
Inflammation may be absent in ulcera- 
tion, 151. 
causing delayed menstruation, 375. 



INDEX. 



601 



Inflammation in sore nipples, 176. 

of vaginal mucous membrane, 591. 
Influenza, epidemic, a cause of cervical 

endo-metritis, 348. 
Influence of age upon conception, 38. 

of season and climate upon men- 
struation, 49. 
Injections, intra-cervical, 357. 

for vaginal and uterine disorders, 

72. 
vaginal, intolerance of, 74. 
Injuries during pregnancy, toleration of, 

336. 
Insanity and eruptions, 108. 
Insanity from hysteria, diagnosis, 292. 
Insomnia in puerperal convulsions, 245. 
Inter-menstrual treatment of leucorrhcea, 

24. 
Intermittent .abortion, 54. 
' menstruation, 586. 
Intermissions, menstrual, common, 563. 
Interstitial fibroids, 547, 549. 

sources of fallacy in recognizing, 

553- 

treatment of, 551-2. 
Intra-uterine astringents, 71. 

growths in dysmenorrhcea, 394. 
Iron in chlorosis, 104. 

Iron, perchloride of, for treating pedicle, 
540. 

at white heat for searing stump, 
540. 
Irritation, ovarian, peculiar, 359. 

by post-organic products, 234. 
Irritable uterus, case, 483. 

causes, 481-2. 

from early abortion, 483. 

hysteralgia, 480. 

limited to menstrual life, 481. 

prescription for, 490. 
Isolation in infantile leucorrhcea, 592. 

J. 

Jaundice and chlorosis compared, 101-2. 

L. 

Labor counterfeited by hysteria, 299. 

a predisposing cause of endo-me- 
tritis, 346. 
premature, induction of, 70. 
a predisposing cause of procidentia 

uteri, 91. 
premature, to be avoided if possi- 
ble, 248. 
Lachesis in ovaritis, 138. 

in interstitial fibroids, 552. 
Lactation, ill effects from too prolonged, 

33- 

while menstruating, 207. 
with sore mouth, 211, 216. 



Lacteal secretion impaired by leucorrhcea 

41. 
Latero-flexion, causes, 577. 

contingent diseases, 580. 

of the uterus, 577. 

physical signs of, 579. 

postural treatment, 579. 

repositing the organ, 579. 

relative frequency of, 577. 

need of courage in treatment of, 

579- 
symptoms, 577. 
Latero-version from overloaded rectum, 

271. 
Lesions, glandular, 345. 

from self-inflicted wounds in pru- 
ritus, 157. 
Leucocytosis, 373. 
Leucorrhcea causing barrenness, 23. 
substituting menstruation, 22. 
treatment of, 23, 44. 
affecting the health of the child, 43. 
infantile, symptoms, 590. 
treatment, 591. 
diet in, 44. 
and scrofulosis, 41. 
inter-menstrual treatment of, 24. 
uterine, 344. 
exciting causes, 347. 

and ulceration from prolapsus ute- 
ri, 151. 
and uterine displacement, with 

headache, 264. 
with chronic ovaritis, 20. 
in vulvo-vaginitis, 588. 
a cause of impairing the lacteal se- 
cretion, 41. 
cervical, treatment of, 354. 
versus uterine catarrh, 346. 
constitutional effects of, 350. 
examination of the flow, 359. 

varying character of the flow, 349. 
Ligation of tumors, 539. 
Linear ulcers in sore nipples, 174. 
Liver, in chlorosis, organic lesions of, 96. 
and spleen enlarged, diagnosis from 

ovarian dropsy, 373. 
and uterus, relation between, 143-4, 
146. 
Lumbar and sacral pains in prolapsus 

uteri, 149. 
Luxations, uterine, at puberty, 14S. 
Lying-in, ovaritis as a contingent of, 131. 
Lymphatic stimulants in leucorrhcea, 45. 



M. 



Magnetism and electricity in menstrual 

headache, 270. 
Malingering in hysteria, 285. 
Mal-presentation, pulsatilla in, 70. 



602 



INDEX. 



Mammary abscess, a criterion of danger 
from, 35. 

diet in, 36. 

from sore nipples, 173. 
Mammary gland, abscess of, 49. 

treatment of, after weaning, 31. 
Marriage in chlorosis, 106. 

as a remedy for suppression, 326. 
Mechanical expedients causing ovaritis, 
in. 

origin of puerperal convulsions, 232. 
Medical treatment of prolapsus uteri, 20. 

causing ovaritis, ill. 
Medication in uterine surgery, 413. 
Medicinal causes of abortion, 339. 
Medicine vs. surgery in menorrhcea, 423. 

and surgery not antidotal or antag- 
onistic, 480. 
Membrane, dysmenorrhceal, identical with 
decidua vera, 189. 

anatomical peculiarities of, 189. 
Membranous dysmenorrhcea, 182. 

causes, 188. 

diagnosis from abortion, 193. 

prognosis, 193. 

treatment, 194. 

therapeutics of, 194. 
Menopause, case, 499. 
Menorrhagia, 560. 

and ovaritis, 120. 

absent in fibro-cystic growths, 371. 

and tuberculosis, 47. 

from polypi, 73. 

sometimes critical, 71. 

infrequent in dysmenorrhcea, 397. 

sudden suppression of, 70. 

in case of fibroids, 548. 
Menorrhcea, cervical epistaxis, case, 419. 

relation to menstruation, 420. 

peculiarity of the flow, 421. 

its critical nature, 421. 

necessity of physical examination 
in, 422. 

haemorrhage persisting, 422. 

medicine vs. surgery in, 423. 

sterility from, 423. 

not to be confounded with '' una- 
voidable haemorrhage," 423. 

general therapeutics of, 424. 

remedies, 103, 424, 425. 
Menses, arrest of, remote disease from, 57. 

in chlorosis, wrong to force, 104. 
Menses, retention of, etiology, 389. 

symptoms, 389. 

diagnosis, 389. 

prognosis, 390. 

treatment, surgical, 390. 

reposition of the uterus, 390. 
Menses, suppression of, 324. 

an uncertain sign, 325. 
Mensium suppressio, insidious complica- 
tions of, 381. 



Menstrual decidua, clinical history and 
confirmation, 190, 191. 
regularity of its appearance, 191. 
expulsion of membrane, 191. 
the " flow " proper with, 192. 
reflex gastric symptoms, 192. 
reflex cardiac symptoms with, 192- 

I 193. 

I Menstrual complications, symptomatic in 

chlorosis, 101. 
J Menstrual disorders, 570. 
in menorrhcea, 422. 
ovarialgia incident to, 164, 165. 
cause of, 583. 

coincident with hysteria, 316. 
causing endo-cervicitis, remedies 

for, 361. 
in ovaritis, 119. 
a sequel of cellulitis, 450. 
Menstrual functions in spinal irritation, 
520. 
! Menstrual headache, case, 262. 
cause, 264, 265. 

search for the primary lesion, 266. 
diagnosis from " sick " headache, 

etc., 266, 267. 
peculiarities of, 266, 267. 
of reflex origin, 263. 
prognosis of, 268. 
treatment for, 269, 270. 
Menstrual intermissions common, 563. 
irregularities in chlorosis, 96. 
life, duration of, 500. 
molimen and hysteria, 281. 
neuralgia, varieties of, 106. 
neuralgia, pain in the left side in, 

107. 
and nervous functions, 564. 
retention a cause of uterine dis- 
placements, 197. 
sequela? in ovaritis, 133-140. 
Menstrual suppression, super-involution 
of the uterus, 382. 
nervous and vascular symptoms, 

382. 
the amenorrhceal cachexia, 383. 
diagnosis of, from pregnancy, 383. 
relieved by time, 384. 
treatment, 384. 

with pectoral complications, 385. 
with ophthalmia, 385. 
remedies for, 386, 387. 
general treatment, 388. 
treatment at the month, 388. 
Menstruation, bad practice, 563. 
Menstruation, delayed, 374. 

a congenital defect, 374. 
the sequelae of inflammation, 375. 
Menstruation during lactation, 207. 
and tuberculosis, 46. 
influenced by season and climate, 
49. 



INDEX. 



603 



Menstruation and molar pregnancy, 39. 

intermittent, 586. 

irregular, a cause of prolapsus, 149. 

preceded by uterine colic, 203. 

relation of, to menorrhcea, 420. 

substituted by leucorrhoea, 22. 
Menstruation, suppressed, etiology of, 379. 

from change of climate, etc., 380. 

from an idiosyncrasy, 380. 

hereditary tendency to, 379. 

not retention, 378. 
Menstruation sometimes too frequent in 

incipient phthisis, 46. 
Meatus urinarius, vascular tumor of, 574. 
Mental emotions in puerperal convulsions, 
241, 243. 

worry in cases of disturbed men- 
struation, 49. 

remedies in hysteria, 306, 312. 

state in chlorosis, 97, 103. 
Mercurius in stomatitis, 220. 

corrosivus in pregnancy, 555. 

vivus in ovaritis, 138. 
Metritis, acute cervical, prognosis and 
treatment, 277. 

chronic cervical, 569. 

corporeal, from cervicitis, diagno- 
sis of, 572. 
Metritis, cervical, the monthly cycle a 
predisponent, 275. 

contact a cause, 570. 

prevention of, 278. 
Metrorrhagia after abortion, 565. 
Mineral waters in chlorosis, 106. 
Miscarriage as a contingent of convul- 
sions, 248, 
Molar pregnancy, 37. 

cause of delivery in, 40. 

and menstruation, 39. 
Moles, 37. 

Morbid anatomy of false conception, 37. 
Morning sickness, a possible cause of, 26. 

apt to return at night, 27. 

of pregnancy, with retroversion, 25. 

salutary, 27. 
Motion increasing the suffering from ab- 
dominal cramps, 62. 
Mucous membrane, cervical, extent of, 

345- 
uterine, in ovaritis, implication of, 

134- 

Muriatic acid in stomatitis, 222. 
Mustard in puerperal convulsions, 256. 



N. 



Naja in ovarialgia, 169. 
Narcotics in hysteria, objections to, 309. 
Natrum muriaticum in stomatitis, 221. 
Nephritis and urethritis, 180. 
Nervous disorder in dysmenorrhea, 397. 
and menstrual functions, 564. 



I Nervous origin of puerperal convulsions, 
232. 

symptoms, symptomatic, 58. 

symptoms at the climacteric, 503, 
508. 

and hysterical symptoms, reme- 
dies, 362. 
Nervous theory of chlorosis, 99. 
Neuralgia, cutaneous, diagnosis from spu- 
rious peritonitis, 63. 

ovarian, 161-165. 

supra-orbital with amenorrhcea, 
106. 

at the climacteric, 505. 

and eruptions, 108. 

varieties of menstrual, 106. 

at the climacteric, remedies, 509. 
Neuralgic diathesis in menstrual head- 
ache, 270. 
Neuralgic dysmenorrhea, case, 405, 408. 

physical exploration in, 407. 

symptoms of, 408. 
Neuralgic headache, diagnosis from men- 
strual, 267. 

pain in chlorosis, 105. 

symptoms in spinal injury, reme- 
dies, 522. 

subjects liable to uterine colic, 203. 
New provings by woman a necessity, 417. 
Nipples, excoriated, 170-176. 

most frequent in primiparae, 171. 

causes, 171. 

symptoms of, 171. 
Nipples, sore, cleanse before nursing, 175. 

treatment, 173, 174, 175. 

choice of shield, 175. 
Nitric acid in stomatitis, 219. 

in uterine haemorrhage, 565. 

for menorrhagia, 560. 

special indications for, 567. 

in menorrhcea, 426. 
Nosological distinctions, 584. 
Notalgia, 510. 
Nursing, cleanse sore nipples before, 175. 

sore mouth, 210-222. 
Nymphomania from ovaritis, 136. 

with hysteria, 303. 



Obstinate vomiting, with amenorrhcea, 

474- 
Obstructive dysmenorrhcea, definition of, 

393- 
Olive oil in ovarialgia, 167. 
Ophthalmia, with menstrual suppression, 

385. 
Organic disease of uterus and ovaries, 163. 
Os uteri, indiscriminate cauterization of, 24. 
and perineum, rigidity of, in p. con- 
vulsions, 257. 
Ovarialgia, clinical history of, 163. 



604 



INDEX. 



Ovarialgia in pregnancy, 165. 

treatment and prognosis, 165-7. 

diagnosis of, from hernia, 165. 

do. from uterine neuralgia, 165. 

and the neuralgic diathesis, 161. 

diagnosis of, from ovaritis, 165. 
Ovarian complications in menorrhoea, 425. 

cyst causing tumors, 369, 534. 

cysts and fibro-cysts compared, 372. 

disease, exemption from, 64. 

dropsy and ascites co-existing, 366. 
Ovarian dropsy, differential diagnosis of, 

363. 
from pregnancy, diagnosis, 366, 

368. 
distinguished from distension and 

prolapse of bladder, 372. 
and pregnancy co-existing, 368. 
and pregnancy, changes in the cer- 
vix, 367. 
from fibro-cystic growths, diagno- 
sis, 371. 
a rare case, 367. 

diagnosis of, from physometra, 372. 
distinguished from fibroids, 369, 

428-9,_ 542. 
and uterine fibroids may co-exist, 

_370. _ 
diagnosis of, from ascites, 364-5. 
distinguished from tumors caused 
by menses or faeces, 373. 
Ovarian dysmenorrhcea, III. 
Ovarian enlargements, location and growth 

of, 367. 
Ovarian implication in spinal irritation, 

517. 

Ovarian irritation, a pathognomonic sign 

of, 557-. 
complications of, 557. 
exciting causes of, 558. 
peculiar predisponents of, 161-2. 
remedies for, 559. 
" stopping " the flow, 564. 
Ovarian symptoms in hysteria, 317. 

in spinal irritation, remedies for, 

522. 
significant in dysmenorrhoea mem- 
branous, 195. 
Ovarian atrophy and induration, 140. 

disease, reflex, remedies for, 361. 
influence, Oldham's theory of, 190. 
irritation, case, 556, 558. 
remedies for, 361. 
Ovarian neuralgia, 161, 165. 
Ovarian tumors, resolution of, 132. 
Ovaries and uterus, organic disease of, 163. 

and cervix, sympathy between, 22. 
Ovaries, extirpation of, 545. 
Ovario-pectoral sympathies in menstrual 

suppression, 381. 
Ovaritis causing uterine and vaginal ca- 
tarrh, 22. 



Ovaritis, consequences of structural 
change in, 133. 

danger from suppuration in, 131. 

diagnosis in, 130. 

character of the pus in ovarian ab- 
scess, 127. 

chronic, with leucorrhoea, 20. 

burning pain in, 21. 

sometimes caused by ovulation, 

21. 

epidemic, 112. 

from medical and mechanical 

causes, 111. 
the vaginal " touch" in, 116. 
characteristic pains in, 116. 
the rectal "touch" in, 117. 
the double " touch" in, 117. 
feeling of strangulation in, 118. 
exercise, position in, 114. 
after abortion, danger from, 131. 
as a contingent of lying-in, 131. 
drain from excessive discharge in, 

133- 

gonorrhoeal, 121. 

barrenness from, 135 140. 
Ovaritis from dysmenorrhcea, ill, 119. 
Ovaritis generally symptomatic, no, 113, 
130. 

haemorrhage into the ovary in, 126. 

liability to suppuration, 127. 
Ovaritis and menorrhagia, 120. 
Ovaritis, menstrual disorders in, 119. 

menstrual sequelae in, 133-140. 

prognosis in, 130. 

the lesions vary in, 124. 

the sub-acute form most frequent, 
no. 

traumatic, 112. 

pathological anatomy in, 124. 

natural and morbid follicle in, 125. 

diagnosis from ovarialgia, 164. 

implication of uterine mucous mem- 
brane in, 134. 

baths, etc., in, 142. 

nymphomania from, 136. 

outlets for pus in, 128. 

peritoneal, 114. 

quantity of pus found in, 129. 

protect from cold and dampness, 
142. 

dropsy as a sequel in, 126. 

sexual intercourse in, 142. 

sequelae of, 133. 

sterility from, 134, 140. 

vesical symptoms in, 118. 

variolous, 130. 

treatment of, 136-7. 
Ovary, reflex relations of, 21. 
Over-exertion may induce abortion, 53. 
Ovulation a constant cause of ovaritis, 21. 

connected with cephalalgia, 265. 

defective, 587. 



INDEX. 



605 



Palliatives in ovarialgia, 167. 
Paralysis and eruptions, 108. 
Paralysis in menstrual life, 564. 

of the rectum causing constipation, 
271. 
Paralysis and prolapsus uteri, 150. 
Paralysis in chlorosis, 102. 
Paralysis a sequel of the apoplectic form 

of puerperal convulsions, 243. 
Parturition a cause of uterine deviation, 

18. 
Pathogenesis in uterine therapeutics, 419. 
Pathognomonic sign in ovarian irritation, 

557- 
Pathological anatomy of fibroid tumors of 
the uterus, 529. 
of ovaritis, 124. 
Pathological kaleidoscope, hysteria a, 

315. 

Pathology, uterine, and diagnosis, 418. 

old ideas concerning, 413. 
Pathology, special, importance of, 23. 
Pectoral disease, diagnosis of, from hys- 
teria, 289. 
Pelvic abscess, 438. 
Pelvic cellulitis, 438. 

case, 452-4. 

diagnosis of, 455. 

treatment of, 455. 

consequences of, 456. 

pathology of, 456. 

means for preventing effusion in, 

456- 
allied to erysipelas, 445. 
distinguished from fibroids, 543. 
essential nature of, 445. 
local adjuvants in, 459. 
remedies for effusion in, 459. 
Pelvic pains and sufferings, 350. 

peritonitis, etc., compared with cel- 
lulitis, 447-8. 
Perineal pad in treatment of prolapsus 

uteri, 19. 
Perineum and os uteri in puerperal con- 
vulsions, 256. 
Peritoneal adhesions in ovarialgia, 164. 

ovaritis, 114. 
Perimetritis, 438-9. 

Peritonitis, caused by sub-peritoneal j 
fibroids, 541. 
diagnosis of, from hysterical deliri 
um, 297. 
Peritonitis, pelvic, and cellulitis, may co 

exist, 449. 
Peritonitis, hysterical form of, 297. 

puerperal, 243. 
Peri-uterine cellulitis, diagnosis of, 447. 
prognosis of, 450. 
causes of, 445-6. 
various synonyms, 439. 



Peri-uterine cellulitis, diagnosis of the 
presence of pus in, 444. 
frequency of, 440. 
and its coincident diseases, ^46. 
symptoms of, 442. 
course and duration of, 443. 
third stage of, 443. 
varied means of escape of pus in, 

445- 
fourth stage of, 443. 
fluctuation in, 444. 
symptoms of, 440. 
Peritonitis, spurious, 62. 
Pertussis causing procidentia uteri, 90. 
Pessaries, 357. 

contra-indications for, 153. 
use of, in retroversion, 30. 
Phthisis complicated with delayed men- 
struation, 376. 
in climacteric, remedies for, 507. 
incipient, too frequent menstrua- 
tion in, 46. 
Physiological cause of menorrhcea, 420. 
Physometra, case, 470. 
diagnosis of, 472. 
treatment of, 473. 
suction of air into the womb in, 

472. 
the tumor in, 471. 
causes of, 472. 

diagnosis from ovarian dropsy, 372. 
Placenta adherent, a cause of haemorrhage, 
76. 
removal of, 80. 
Pleurisy simulated by hysterical sideache, 

298. 
Pleuro-pneumonia in hysteria, 305. 
Predispositions hereditary in climacteric, 

506. 
Pregnancy, albuminuria in, 554. 
bilious colic during, 143. 
abdominal cramps and pains 

in, 61. 
changes in the breasts in, 327. 
changes in the cervix in, 328. 
chlorosis in, 97. 
cholestraemia and uterine disease 

in, 145. 
diagnosis of great importance, 324. 
diagnosis from menstrual suppres- 
sion, 383. 
growth of cellular tissue in, 440. 
differential diagnosis of, from uter- 
ine ulcer, 323. 
distinguished from sub-peritoneal 

fibroids, 542. 
signs of, 39. 
excessive abdominal development 

in, 66. 
and dropsy may co-exist, 369. 
morning sickness of, 25. 
ovarialgia in, 165. 



606 



INDEX. 



Pregnancy and ovarian dropsy, changes in 
the cervix in each, 367. 
and ovarian dropsy, frequently con- 
founded, 366, 368. 
size of abdomen a sign and 

sequence of, 67. 
gastro-intestinal disordei-s incident 

to, 64. 
simulated in climacteric, 502. 
pruritus during, 158. 
tolerance of exercise in, 54. 
toleration of injuries during, 336. 
Poisoning, indirect, of nursing children, 

43- 
Polypi causing menorrhagia, 73. 

fibrous, causing tumors, 535. 
Position in urethritis, 181. 
Post-dysmenorrhoeal haemorrhage, 567. 

-menstrual haemorrhage, 567. 

-partum convulsions, danger of, 241. 

-partum ulceration of the womb, 
204. 

-partum ulceration, cure easy, and 
why, 207. 

-puerperal cause of cervicitis, 571. 
Postural treatment of prolapsus, 19, 

treatment of retroversion, 29. 
Posture in diagnosis of ascites from ovar- 

rian dropsy, 356. 
Practical distinction in uterine haemor- 
rhage, 564. 
Premature labor, the induction of, 70. 

a radical cure for stomatitis, 218. 

when if ever justifiable, 249. 
Pressure, effects of, in sub-peritoneal fib- 
roids, 541. 
Prae-partum convulsions not so dangerous, 

241. 
Pretexts for weaning infants, 32. 
Probable signs of pregnancy, 39. 
Procidentia uteri, labor predisposes to, 91. 

from pertussis, 90. 
Prodroma, early recognition of in puer- 
peral convulsions, 245. 
Prodromata in spinal irritation, 582, 
Prognosis in ovaritis, 130. 

qualified, 585. 

in uterine haemorrhage, 78. 
Prophylactic for convulsibility, 556. 

treatment of galactorrhea, 34. 

treatment in hysteria, 316. 
Prophylactics for sore nipples, 173. 
Prophylaxis of bilious colic during preg- 
nancy, 147. 

in interstitial fibroids, 552. 

in ovarialgia, 166. 
Prolapsus caused by constipation at cli- 
macteric, 18. 

the exciting cause of, 476. 

caused by dropsy at climacteric, 18. 
Prolapsus uteri with amenorrhcea, 474. 

causing amenorrhcea, 476. 



Prolapsus uteri and paralysis, 150. 
with dropsy, 17. 
with ulceration, 147 to 154. 
caused by irregular menstruation, 

149. 
dating from climacteric, 17. 
hygienic precaution in, 19. 
the cramping pains, 272. 
pseudo-, 84. 
frequency of, 85. 
postural treatment of, 19, 153, 

I54-. 

with right latero-version, 270. 
spontaneous cures of, 86. 
remedies employed for, 19. 
treatment, leading indication of, 

273- ; 

the vesical symptoms in, 272. 

remedies, 273, 274. 
Prolonged lactation, ill effects of, 33. 
Promises qualified, 585. 
Promoting uterine contraction, 80. 
Provings, new, by women a necessity, 417. 
Proper time for weaning, 33. 
Prurigenous eruption of vulva, symptoms 
of, 587. 

vulvitis, 585. 
Pruritus at the climacteric, 157. 

during pregnancy, 158. 

limited to period of lactation, 158. 

with uterine disease, etc., 158, 159. 

of the vulva, causes of, 155, 156. 

— treatment of, 159, 160. 

from trichiasis, 156. 
Pseudo-membrane in ulceration of the 
os, 436. 

prolapse of the uterus, 84. 
Puberty delay of, etiology of, 374. 

diseases of, may return at climac- 
teric, 501. 

emmenagogues at, 562. 

uterine luxations at, 148. 
Puerperal convulsions, albuminuria in, 
234, 244, 247- 

case, 223, 259. 

diagnosis of, 237. 

the hysterical form of, 237. 

the apoplectic form of, 238. 

the epileptiform variety of, 238. 

brain symptoms in, 229. 

the pulse in, 230. 

etiology and predisposing causes 
of, 230. 

exciting causes, 230. 

Bright's disease a concomitant, 
236, 246. 

unfavorable symptoms of, 240. 

vision impaired in, 244. 

preventive treatment, tact, 244. 

remove possible exciting causes, 
244. 

diet in, 245. 



INDEX. 



607 



Puerperal convulsions, benefits of cheerful 
society, 245. 

manner of physician in treating, 

245-. 

rupturing the membranes, 250. 

the forceps in, 250, 257, 259. 

emptying the bladder in, 250. 

fecal accumulation ; clot a cause, 
250. 

cold water, ice, etc. in, 250. 

the convulsive stage of, 228. 

danger to the child from, 242. 

dropsy a precursory symptom, 228. 

following colic, pleurisy, etc., 246. 

following local paralysis, 246. 

frequency of, 225, 261. 

epileptic, hysterical, apoplectic, 
225. 

forebodings before delivery, 241. 

noting progress of labor, 249. 

pathological anatomy of, 236; 

the patient's posture in, 247. 

rigidity of os uteri and perineum 
in, 257. 

curative treatment of, 260. 

are the potencies efficacious in con- 
trolling? 261. 

opiates prohibited in, 252. 

prognosis, mortality from, 239. 
Puerperal ovaritis, treatment of, 137. 
Puerperal convulsions, the toxaemic theory, 

233- 
controlling the symptoms in, 247. 
palliative treatment of, 248. 
peculiarities of, 229. 
Pulmonary affection in chlorosis, 102. 

disease a sequel of puerperal 
eclampsia, 243. 
Puriform discharge in endo-metritis, 349. 
Pulsatilla in mal-presentations, 70. 
Pulse, the, in chlorosis, 95. 

in hysteria, 
Pus in ovaritis, ch .icter of the, 127. 

outlets for, 8. 
Pus, quantity forn d in ovaritis, 129. 
Quackish claims i cases of pseudo-pro- 
lapse, 8' 
Qualifying the p gnosis in uterine haem- 
orrhage 78. 
your promises, 585. 



R. 



Rectum overloaded, causing latero-ver- 

sion, 271. 
Rectal and vesical complications in dys- 
menorrhcea, 396. 

troubles, remedies for, 362. 
Reflex gastric symptoms in pregnancy, 
26. 
relations of the ovary, 21. 



Remedies, alternation of, 87. 

for reflex ovarian disease, 361. 
for treatment of prolapsus, 19. 
Remote disease from arrest of menses, 57. 
Removal of placenta, 80. 
Replacing the womb in retroversion, 28. 
Resolution of ovarian tumors, 132. 
Resources, impromptu, in hysteria, 89. 
Respiratory system, disorders of the, in 

climacteric, 504. 
Rest and quiet in amenorrhcea, 60. 
Restoratives in hysteria, 313, 316. 
Retention of the menses, etiology, causes, 
389. 

and suppression, difference be- 
tween, 57. 
Retroflexion of the womb, distinguished 

from fibroids, 542. 
Retroversion — Abortion a contingent of, 

27. 

and morning sickness, 25. 

and retroflexion causing tumors, 
535. 

causing morning sickness, 26. 

of the womb, distinguished from 
fibroids, 542. 

persisting to term, 30. 

postural, treatment of, 29. 

treated with pessaries, 30. 

treatment of, 28. 
Rheumatic complications in membranous 
dysmenorrhcea, 194. 

diathesis in ovarialgia, 162, 165, 
166, 167. 

pains in chlorosis, 105 

symptoms in spinal injury, reme- 
dies, 522. 
Rheumatism counterfeited in hysteria, 
298. 

in climacteric, 505. 

at the climacteric, remedies, 509. 

and hysteria with ovarian irritation, 

with vulvo-vagin 1 ^ 
Rhus toxicodend .,.omati 



S. 



Scrofulosis and leucorrhcea, 41. 

Scrofulous cachexia in menorrhcea, 424. 

Scrofulosis and chlorosis, 98. 

predisposing to uterine catarrh, 
346. 

Sea-bathing in chlorosis, 106. 

Season and climate affecting menstrua- 
tion, 49. 

Secondary effects of hysteria, 2S6. 

Senses, special disorders of, in climacteric, 

, 504. 

Sequefe of abortion — case, ^34, 339, 
340. 



608 



IXDEX. 



Sequelae of abortion in ovaritis, 133. 

of uterine haemorrhage, 78. 
Sewing machines and uterine diseases, 

276. 
Sexual congress forbidden in prolapsus 
uteri, 153. 

desire ungratified causing irritable 

uterus, 4S2. 
excitement in ovarialgia, 162. 
intercourse in ovaritis, 142. 
Shield for sore nipple, benefit of, 175. 
" Sick " headache, diagnosis, from men- 
strual headache, 266. 
Significance of aphonia with too frequent 

menstruation, 4S. 
Signs of danger in haemorrhage, 78. 

of pregnancy, 39. 
Sinapisms in puerperal convulsions, 256. 
Size of abdomen a sign and sequence of 

pregnancy, 67. 
Skin, discoloration of, in chlorosis, 97. 

disease and hysteria, 10S. 
Slipperv elm in treatment of sore nipple, 

176. ' 
Society, cheerful, in chlorosis, 106. 
Sophistries of the abortionist, 336. 
Sore nipples, mammary abscess from, 172. 
Sore mouth, capricious nature of the 
lesions, 214. 

causes of digestive derangement, 

214. 
renal and vesical symptoms, 215. 
Souffle, uterine, in pregnancy, 327. 

uterine, in pregnancy unreliable, 

36S. 
uterine, in tumors of uterus, 532. 
Spanaemia in chlorosis, 94. 
Spasms or convulsions ? 88. 

— hysterical, resembling chorea, 

56. 
in menstrual life, 564. 
Special pathology, importance of, 23. 
indications for nitric acid, 567. 
Speculum not necessary, 320. 

and uterine sound, conjoined use 
of, 497. 
Spleen in chlorosis, organic lesions of, 96. 
and liver enlarged, not ovarian 
dropsy, 373. 
Spontaneous cures of prolapsas uteri, 86. 
Spurious peritonitis, 62. 

symptoms in hysteria, 2S4. 
Spinal injury, remedies for, effects of, 522. 
Spinal irritation, 510. 
case, 511, 512. 
causes, 513, 515. 
diagnosis, 518, 519. 
diagnosis from inflammation of the 

cord, etc., 519. 
peculiar organization a predispo- 

nent, 513. 
of nervous origin, 515. 



I Spinal irritation, symptoms, 515. 

from injury in the sacral region, 

5I5 : 
from injurs' in the dorsal region, 

5 l6 ; 
from injury in the cervical region, 

516. 

from incidental causes, 516. 

at the climacteric, 521. 

prognosis, 520. 

treatment, 520, 522, 523. 

itinerant patients, 520. 

and tenderness in chlorosis, 105. 

from centric and eccentric action, 
516. 

and uterine disease, 517. 

tact and sympathy, 521. 

and the menstrual functions, 520. 

in amenorrhoea, 521. 

use of sponge-tent, 521. 

local adjuvants, 522. 

remedies and expedients, 523. 

in post traumatic cases, 518. 

Faradization, 524. 

reflex symptoms, 517. 

case, 583. 

nature of the disease, 582. 

with amenorrhoea, etc., 580. 

failure of dilatation, 583. 

or hysteria? 302. 

incision of cervix, 583. 

secondary diseases, 518. 

use of remedies, 582. 

with convulsions, causes of, 583. 
Sponge-tent, 105, 196, 200, 329, 330, 521. 

as a haemostatic, 537. 

as a means of diagnosis, 329. 

mode of applying, 330. 

new use of, 329. 

use of, in chlorosis, 105. 

in spinal irritation, 521. 
Sterility, caused by leucorrhoea, 23. 

from obstructive dysmenorrhcea, 

397- 
and fibroids, 549. 
from menorrhcea, 423. 
a sequel of pelvic-cellulitis, 450. 
from ovaritis, 134, 140. 
Stimulants in uterine haemorrhage, 82. 
Stimulation, alcoholic, in hysteria, 309, 
310. 
. Stomach and uterus, reflex relations be- 
tween, 319. 
Stomatitis, follicular, 213. 

local ulceration in, 214. 
Stomatitis materna, (nursing sore mouth), 
210, 222. 
anaemia in, 215. 
symptoms of, 211, 212. 
diagnosis and prognosis of, 216. 
treatment for, diet in, 218, 219, 
222. 



INDEX. 



609 



Stomatitis materna, rules for choosing 
drinks in, 218. 

limited to gestation and lactation, 

211, 227. 
peculiarities of, 21 1, 213. 
Stomatitis, change of climate in, 219. 
local treatment for, 222. 
the induction of premature labor, 

as a remedy for, 218 
weaning the child in, 219. 
Stone, diagnosis from urethritis, 180. 
Strangulation feeling of, in ovaritis, 

118. 
Structural changes in ovaritis, consequen- 
ces of, 133. 
Sub-mucous fibroids, Dr. Atlee's operation 
for, 537. 

sessile, or pedunculated, 530. 
Sub-peritoneal fibroids, 540. 
diagnosis of, 541. 
course and termination of, 544. 
prognosis and treatment of, 544. 
symptoms of, 540. 
effects of pressure in, 541. 
coincident disorders of, 541. 
surgical treatment of, 545, 546. 
Sudden suppression of menorrhagia, 70. 
Sulphuric ether in puerperal convulsions, 

251- 

Sulphuric acid in stomatitis, 220. 
Suppressed menstruation, course and fre- 
quency, 379. 

incident to acute disease, 380. 
Suppression of menses, avoidable causes 
of, 379. 

troubles from, 59. 
Suppression and retention, difference be- 
tween them, 57. 
Suppression, producing uterine displace- 
ments, 199. 

of menses from chronic disease, 

380. 

Suppresiomensium, emmenagogues, 385. 

essentially a glandular disease, 381. 

from trivial causes, 380. 

Support for the breasts in galactorrhea, 

Suppuration in ovaritis, danger from, 131. 

liability to, 127. 
Surgei'y uterine, claims of, illustration, 
412. 

not perfect, 584. 
causing uterine cellulitis, 446. 
value of, 411, 414, 416. 
Surgery and medicine not antidotal, 480. 
versus medicine, in menorrhoea, 

423- 
versus therapeutics, 411, 414, 416. 
Susceptibility of bodily tissues to organic 

poisoning, 235. 
Sympathy between the cervix and the 
ovaries, 22. 

39 



Sympathy between generative organs and 

the heart, 94. 
Symptomatic nervous symptoms, 58. 
Symptomatology in uterine therapeutics, 

419. 

Symptoms of endo-metritis, 348. 

remotely located in uterine disor- 
der, 146. 
in ovaritis, 113, 130. 
versus pathology , in prolapsus uteri, 

I 5 I - 
Syphilitic cachexia, in menorrhoea, 425. 



Tact versus talent in the treatment of 

hysteria, 312. 
Tapping, in the diagnosis of ovarian 

dropsy, 365. 
Taxis and reduction of procidentia uteri, 

92. 
Tea and coffee causing irritable uterus, 

482. 
Tenaculum, the uterine, 549. 
Tenesmus, uterine, causing dysmenor- 

rhoea, 396. 
Tetanic convulsions, 236. 
Therapeutics in menorrhoea, 424. 

versus surgery. 411, 414, 416. 
Therapeutics, uterine, not to be neglected, 

414, 415- 
sometimes ignored, 412. 
not perfect, 584. 
Tolerance of exercise in pregnancy, 53. 
Topical expedients in uterine irritability, 

489. 
" Totality of the symptoms," 477. 
Touch and consistence of tumor in ova- 
rian dropsy, 365. 
Toxaemic theory in puerperal convulsions, 

233. 

Traumatic causes of spinal irritation, 513. 

ovaritis, 113. 
Travel and exercise in chlorosis, 105. 
Treatment of abdominal cramps and 
pains, 65. 

of leucorrhoea, 44. 

of mammary glands after weaning, 

31. 
of ovaritis, 137, 141. 
uterine haemorrhage, 79. 
Trouble from suppression in amenorrhcea, 

59- ' . . 

Tuberculous diathesis at the climacteric, 

506. 
Tuberculosis in chlorosis, 102. 

and menstruation, 47. 

and menorrhagia, 47. 

predisposing to uterine catarrh, 

34 ?\ 
Tumor, location of, in peri-uterine cellu- 
litis, 442. 



610 



INDEX. 



Tumor, excision of the, 537. 

intra-mural, dilatation, 550. 

in physometra, 471. 

in vagina, very large, 539. 

in the vagina or uterus, 538. 
Tumors, bi-manual examination of, 533. 

Dr. Atlee's operation, 554. 

Dr. Brown's operation, 554. 

diagnosis of, from hydatids, 534. 

diagnosis of, from inversion of the 
womb, 535. 

increased size of the uterus, 533. 

from fibrous polypi, 535. 

from an ovarian cyst, 534. 
Tumors of the uterus, danger from, 535. 

error in diagnosis of, 427. 

fibroid, 547. 

fibroid, number, weight and tex- 
ture, 530. 

fibro-cystic, 426. 

physical signs, 533. 

tolerance of, 532. 
Tumors and fibroids, relative rapidity of 

growth of, 371. 
Tumors, uterine, difficult diagnosis of, 

545- 

use of sound, 493. 
Tumors in vaginismus, excision of, 468. 

ovarian, resolution of, 132. 
Turn of life, case, 499. 
Twin delivery, haemorrhage after, 75. 
Tympanites abdominal, and delirium, 299. 
Typhoid fever, spurious, 264. 



U. 



Ulcer, depth of, and discharge, in ulcera- 
tion of the os, 436. 
Ulcer, uterine, appearance of, 321, 333. 

from pregnancy, differential diag- 
nosis of, 323. 

not limited to the poor, 321. 

remedies for, 322. 

cure the indigestion, 322. 

sign of depraved vitality, 321. 

stop any drain from, 322. 

removal of the mucus, 320. 

treatment, diet, etc., 322, 323. 
Ulcer of the uterine cervix, case, 319, 322. 

treatment of, 334. 
Ulcers, linear, in sore nipples, 174. 
Ulcerated nipples. 173. 
Ulceration, aphthous, of os and cervix 
uteri, 431, 435. 

in sore nipples, 173, 174. 
Ulceration, diphtheritic, of os uteri, 436. 
Ulceration and leucorrhcea from prolap- 
sus uteri, 151. 

from abrasion in prolapsus uteri, 
151, 152. 
Ulceration of the os from constitutional 
causes, 434, 436. 



Ulceration of the os, diet, 434. 

remedies, 434. 

depth of the ulcer, 436. 

treatment, 432, 433, 435, 438. 

diphtheritic, 437. 

diphtheritic, treatment, 438. 
Ulceration of os, aphthous, eruptive stage, 

431. 
symptoms, diagnosis and causes, 

431, 436. 
Ulceration of the stomach in chlorosis, 96. 
of the vaginal mucous membrane, 

591. 
Ulceration of the womb, impaired quality 
of the blood, 206. 
post-partum, 205. 
likely to be overlooked, 205. 
treatment by weaning the child, 

206. 
local treatment, 208, 209. 
a sequel of inflammation, 206. 
diet, walking, riding, 207. 
Ulceration sans inflammation in prolap- 
sus uteri, 151. 
Unnecessary manipulation in pseudo- 
prolapse, 85. 
Ursemia increases convulsibility, 235. 
Urethra and bladder, diseases of, and 

diagnosis, 329. 
Urethritis, 177-182. 
causes of, 178. 

diagnosis of; from stone, 180. 
character of the urine in, 179. 
after excision of tumor, 577. 
obstinate or chronic, 181. 
posture chosen in, 179. 
rapid cures exceptional, 181. 
rest in recumbent position, 181. 
and nephritis, 179. 
the sponge-tent in, 331. 
symptoms of, 179. 
treatment of, 181, 182. 
Urine, character of, in urethritis, 179. 
Uterine affections, venous engorgement 
in, 145. 
astringents, physiological argument 

against, 72. 
cancer, diagnosis of, 571. 
catarrh, not a leucorrhcea, 346. 
Uterine cavity, inflammation of, 588. 
length of the, 370. 
sudden discharge from, 587. 
Uterine cervix, ulcer of, 319, 332. 
use of speculum forceps, 352. 
Uterine colic, 64. 

duration of the attack, 202. 
may precede menstruation, 203. 
in neuralgic subjects, 203. 
hygienic and prophylactic treat- 
ment, 203. 
incident to hysteria, 202. 
incident to dysmenorrhcea, 202. 



INDEX. 



611 



Uterine colic, among intellectual women, 
203. 

palliatives and remedies, 204. 

symptoms, 202. 

causes, 203. ' 

vaginal injections sometimes inju- 
rious, 201. 
Uterine deviations causing fibroids, 547. 

predisposition to, at climacteric 
period, 18. 

resulting from parturition, 18. 

in dysmenorrhea, 394. 
Uterine diagnosis, refinements of, 439. 
Uterine disease, pregnancy and choles- 
traemia, 145. 

with pruritus, 158. 

and spinal irritation, 517. 
Uterine diseases, reflex symptoms, 517. 

and sewing machines, 276. 
Uterine disorder, symptoms remotely lo- 
cated, 146. 
Uterine displacements from carelessness 
at the month, 199. 

chronic, 198. 

from temporary suppression, 198. 

inference, 589. 

in tumors of uterus, 532. 

treatment, 199. 
Uterine displacement -and leucorrhcea, 

with headache, 264. 
Uterine fibroids, from ovarian dropsy, 
diagnosis of, 428. 

deceptive symptoms, 536. 

diagnosis of, from dropsy, 369. 
Uterine haemorrhage after twin delivery 

75- 

alarming nature of, 76. 

nitric acid in, 565. 
Uterine inertia a cause of haemorrhage, 

injections, disorders from, 72. 
Uterine irritability aggravated by surgery, 

.489. 
diagnosis from other diseases, 487. 
diagnosis from dysmenorrhoea, 487. 
diet, mode and time of eating, 487. 
caused by abortion, 483. 
caused by escharotics, 483. 
diagnosis from coccyodynia, 486. 
fresh air and exercise, 488. 
effect of posture and of motion, 

485. . 
contradictory nature of symptoms 

of, 486. 
physical examination, 486. 
location of the pain, 484. 
symptoms of, 484. 
symptoms nervous and capricious, 

485. 
topical expedients for, 489. 
treatment, 487. 

simulating other diseases, 485. 
with convulsions, 248. 



Uterine and vaginal catarrh from ovaritis, 

22. 
Uterine lesion may be latent, 320. 
leucorrhcea, 344. 
luxations and digestive disorders, 

149. 
luxations at puberty, 148. 
modus operandi of most remedies 

for, 200. 
sponge tent useful, 200. 
Uterine mucous membrane in ovaritis, 

implication of, 134. 
neuralgia from ovarialgia, 165. 
obliquities, 326. 
pathologists, old ideas exploded, 

413- 
pathology and diagnosis, 418. 
Uterine souffle in pregnancy, 327. 

in pregnancy, unreliable, 368. 
Uterine sound, 549. 

in diagnosis, 491. 

in deviations of uterus, 493. 

to measure the size of the uterus, 

492. 
for the reposition of the womb, 494. 
kind of, preferable, 495, 498. 
position of the patient for intro- 
ducing, 496. 
in displacements backwards, 496. 
difficulty in using, 495. 
danger in using, 498. 
in carcinoma, 493. 
in 'replacing the womb, 29. 
in uterine displacements, 493. 
in diseases of the cervix, 491. 
in the diagnosis of tumors, 493. 
Uterine sound and speculum, conjoined 

use of, 497. 
Uterine sound, to test the mobility of the 
uterus, 492. 
how to be passed, 495, 498. 
when, why and how used, 491, 494. 
when to be introduced, 494. 
Uterine surgery and therapeutics, 584. 

versus uterine therapeutics, 411, 
414, 416. 
Uterine symptoms in hysteria, 317. 

in spinal irritation, remedies, 522. 
Uterine tenaculum, 549. 
Uterine tenesmus causing dysmenorrhoea, 

395- 
Uterine therapeutics, skill to develop, 415. 
tumors, diagnosis of, difficult, 545. 
ulcer, causes of, 333. 
removal of the mucus, 320. 

ulceration, use of caustics, 154. 
use of calendula, etc., 154. 
wall, tumor attached, 539. 
Utero-cardiac derangements in hysteria, 

318. 
Utero-gastric derangements in hysteria 
318. 



612 



INDEX. 



Utero-gastric disease, key to success in 

treatment of, 478. 
Uterus, expulsive effort of the, 198. 

and liver, relation between, 143-4, 

146. 
and stomach, reflex relations of, 

319. 

depressing the, 549. 
extirpation of, 545. 
fibroid tumors of the, 547. 
fibro-cystic tumor of, case, 426. 
increased size of, by tumors, 533. 
Uterus, irritable, 480. 

no definite lesion in, 481. 

new remedies for, 490. 

use of the sound in diseases of, 491. 

fibroid tumors of the, 529-30. 

latero-flexion of the, 577. 

and ovaries, organic disease of the, 

163. 
and tumor, consentaneous mobility 

of, 370. 
tumor in the, 538. 
tumor of, deceptive symptoms, 427. 



V. 



Vaccination causing complicated symp- 
toms, 582. 
Vagina, tumor in the, 538. 
Vaginal and uterine catarrh from ovaritis, 

22. 
Vaginal injections, disorders from, 72. 

intolerance of, 74. 
Vaginal "touch" in ovaritis, 116, 130. 
Vaginismus, case, 462. 

attendant on hysteria, 303. 

causes of, 465. 

diagnosis of, 466. 

dilatation for, 467. 

excision of irritable tumors in, 468. 

hyperesthesia in, 464. 

local anaesthesia in, 470. 

medical treatment for, 466. 

Dr. Sims' operation for, 469. 

Dr. Tilt's operation for, 468. 

Dr. Burns' operation for, 468. 

scissors and dilatation, 470. 

surgical treatment, 467. 

symptoms, 463. 
Vaginitis in children, causes, 591. 
Valerian in hysteria, 314. 
Valerianate of zinc in ovarialgia, 168. 
Value of tact in hysteria, 89. 
Valvular disease of heart and hysteria, 287. 
Variolous ovaritis, 130. 
Vascular changes in the gravid uterus, 144. 
Vascular tumor of the meatus urinarius, 
574- 

symptoms of, 575. • 



I Vascular tumor, physical exploration, 576. 

excision of, 577. 
J Vegetative growths on the vulva, 588. 

Venesection in puerperal convulsions, 255. 

Venous engorgement in uterine affections, 

.145., 

Veratrin in ovarialgia, 167. 
Veratrum viride for dysmenorrhcea, 410. 
in ovaritis, 138. 
in puerperal eclampsia, 255. 
in pelvic cellulitis, 458. 
Veronica beccabunga in stomatitis, 221. 
Vesicular stage in ulceration of os, reme- 
dies, 434-5. 
Vesical symptoms in ovaritis, 118. 

remedies, 362. 
Vesical and rectal complications in dys- 
menorrhcea, 396. 
Vicarious hsematemesis with spinal irrita- 
tion, 581. 
Vision impaired in puerperal convulsions, 

244. 
Vomiting, excessive, ill effects of, 479. 
obstinate, with amenorrhcea, 474. 
vicarious, with spinal irritation, 
etc., 580. 
Vulvitis, syphilitic, or otherwise, 160. 
Vulvo-vaginitis, causes of, 588. 

diagnosis from granular do., etc., 

588. 
prognosis and treatment, 589. 
color of the eruption in, 588. 
prurigenous vulvitis, 585. 
treatment and remedies for, 590. 



W. 



Weaning the child, 31. 

in leucorrhcea, 44. 
in stomatitis, 219. 
proper time for, 33. 
! What medicine can do in prolapsus uteri, 

86. 
I Whiskey, brandy and wine in hysteria, 
310. 
White jaundice, 97. 
\ Wine, whiskey and brandy in hysteria, 310. 
Womb, effect of replacing the, 476. 

inversion of the, causing tumors, 

535- 

post-partum ulceration of the, 204. 

only specific ulceration needs spe- 
cific local treatment, 208. 

reposition of, in retroversion, 28. 

retention increasing the weight of, 
197. 

ulceration of, treatment, diet, etc., 
206-7. 
Women, diseases of, complicated, 584. 
Worms causing vaginitis in children, 591. 



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